Basic (05-86)
DI 34110.001 Listing of Impairments - Part A (March 27, 1979-January 5, 1986)
1.00 Musculoskeletal System
-
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.
-
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.
-
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.
-
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.)
-
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:
-
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
-
B.
Corroboration of diagnosis at some point in time by either:
-
1.
Positive serologic test for rheumatoid factor; OR
-
2.
Antinuclear antibodies; OR
-
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:
-
A.
Gross anatomical deformity of hip or knee (e.g., subluxation, contracture, bony or
fibrous ankylosis, instability); OR
-
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
-
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:
-
A.
Abduction of both arms at the shoulders, including scapular motion, restricted to
less than 90 degrees; OR
-
B.
Gross anatomical deformity such as subluxation, contracture, bony or fibrous ankylosis,
joint instability, or ulnar deviation.
1.05 Disorders of the Spine:
-
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.
Calcification of the anterior and lateral ligaments; OR
-
2.
Bilateral ankylosis of the sacroiliac joints with abnormal apophyseal articulations;
OR
-
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.
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.
Multiple fractures of vertebrae with no intervening direct traumatic episode; OR
-
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.
Pain, muscle spasm, and significant limitation of motion in the spine; AND
-
2.
Appropriate radicular distribution of significant motor loss with muscle weakness
and sensory and reflex loss.
1.08 Osteomyelitis
(Established by X-ray):
-
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
-
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):
-
-
-
1.10 Amputation of One Lower Extremity
At or above the tarsal region):
-
A.
Hemipelvectomy or hip disarticulation; OR
-
B.
Amputation at or above the tarsal region due to peripheral vascular disease or diabetes
mellitus ; OR
-
C.
Inability to use a prosthssis effectively, without obligatory assistive devices, due
to one of the following:
-
-
2.
Neurological complications (e.g., loss of position sense); OR
-
3.
Stump too short or stump complications persistent, or are expected to persist, for
at least 12 months from onset; OR
-
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
-
A.
Ophthalmology
-
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.
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.
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.
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.
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.
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.
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.
-
B.
Otolaryngology
-
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.
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.
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.
-
A.
To 10 degrees or less from the point of fixation; OR
-
B.
So the widest diameter subtends an angle no greater than 20 degrees; OR
-
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:
-
A.
Disturbed function of vestibular labyrinth demonstrated by caloric or other vestibular
tests; AND
-
B.
Hearing loss established by audiometry.
2.08 Hearing Impairments
Hearing not restorable by a hearing aid. Manifested by:
-
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
-
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).
Snellen |
|
|
Percent Central Visual Efficiency |
English |
Metric |
Phakic 1 |
Aphakic Monocular 2 |
Aphakic Binocular 3 |
20/16 |
6/5 |
100 |
50 |
75 |
20/20 |
6/6 |
100 |
50 |
75 |
20/25 |
6/7.5 |
95 |
47 |
71 |
20/32 |
6/10 |
90 |
45 |
67 |
20/40 |
6/12 |
85 |
42 |
64 |
20/50 |
6/15 |
75 |
37 |
56 |
20/64 |
6/20 |
65 |
32 |
49 |
20/80 |
6/24 |
60 |
30 |
45 |
20/100 |
6/30 |
50 |
25 |
37 |
20/125 |
6/38 |
40 |
20 |
30 |
20/160 |
6/48 |
30 |
— |
22 |
20/100 |
6/60 |
20 |
— |
— |
Column and Use
-
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
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
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.
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.
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
-
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.
-
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.
-
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.
-
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.
Table I
Height (inches) |
MVV (MBC) equal to or less than |
|
|
57 or less |
32 |
|
1.0 |
58 |
33 |
|
1.0 |
59 |
34 |
|
1.0 |
60 |
35 |
|
1.1 |
61 |
36 |
|
1.1 |
62 |
37 |
|
1.1 |
63 |
38 |
|
1.1 |
64 |
39 |
|
1.2 |
65 |
40 |
|
1.2 |
66 |
41 |
|
1.2 |
67 |
42 |
|
1.3 |
68 |
43 |
|
1.3 |
69 |
44 |
|
1.3 |
70 |
45 |
|
1.4 |
71 |
46 |
|
1.4 |
72 |
47 |
|
1.4 |
73 or more |
48 |
|
1.4 |
3.03 Asthma
With:
-
A.
Chronic asthmatic bronchitis. Evaluate under the criteria for chronic obstructive
ventilatory impairment in 3.02A; OR
-
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:
-
A.
Total vital capacity equal to, or less than, values specified in Table II below corresponding
to the person's height.
Table II
Height (inches) |
V.C. equal to or less than (L) |
57 or less |
1.2 |
58 |
1.3 |
59 |
1.3 |
60 |
1.4 |
61 |
1.4 |
62 |
1.5 |
63 |
1.5 |
64 |
1.6 |
65 |
1.6 |
66 |
1.7 |
67 |
1.7 |
68 |
1.8 |
69 |
1.8 |
70 |
1.9 |
71 |
1.9 |
72 |
2.0 |
73 or more |
2.0 |
OR
-
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
-
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.
Table III
Arterial pC02 (mm. Hg) and |
Arterial (p02) equal to or less than mm. Hg. |
30 or below |
65 |
31 or below |
64 |
32 or below |
63 |
33 or below |
62 |
34 or below |
62 |
35 or below |
60 |
36 or below |
59 |
37 or below |
58 |
38 or below |
57 |
39 or below |
56 |
40 or above |
55 |
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.
Table IV
Height (inches) |
V.C. equal to or less than (L) |
59 or less |
1.0 |
60 |
1.1 |
61 |
1.1 |
62 |
1.1 |
63 |
1.1 |
64 |
1.2 |
65 |
1.2 |
66 |
1.2 |
67 |
1.3 |
68 |
1.3 |
69 |
1.3 |
70 or more |
1.4 |
3.06 Pneumoconiosis
Demonstrated by X-ray with:
-
A.
Nodular or focal fibrosis (non-conglomerative). Evaluate under the criteria for chronic
obstructive airway disease in 3.02; OR
-
B.
Interstitial or disseminated fibrosis or conglomerative disease. Evaluate under the
criteria for pulmonary fibrosis in 3.04: OR
-
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:
-
A.
Episodes of acute bronchitis or pneumonia or hemoptysis (more than blood-streaked
sputum) occurring at least once every 2 months; OR
-
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:
-
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
-
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
-
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
-
A.
Severe cardiac impairment
Severe cardiac impairment results from one or more of three consequences of heart
disease:
-
1.
congestive heart failure;
-
2.
ischemia (with or without necrosis) of heart muscle
-
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.
-
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.
-
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.
-
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.
-
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.
-
F.
Documentation of electrocardiography.
-
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.
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.
-
G.
Exercise Testing
-
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.
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.
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.
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.
-
H.
Angiographic evidence
-
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.
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.
Proximal coronary arteries
Proximal coronary arteries (see 4.04B7) will be considered as the:
-
a.
Right coronary artery proximal to the acute marginal branch;
-
b.
Left anterior descending coronary artery proximal to the first septal perforator;
AND
-
c.
Left circumflex coronary artery proximal to the first obtuse marginal branch.
-
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.
-
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:
-
A.
Persistent congestive heart failure on clinical examination despite prescribed therapy;
OR
-
B.
Persistent left ventricular enlargement and hypertrophy documented by both:
-
1.
Extension of the cardiac shadow (left ventricle) to the vertebral column on a left
lateral chest roentgenogram; AND
-
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
-
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.
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.
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
-
D.
Cor pulmonale (nonacute) documented by both:
-
1.
Right ventricular enlargement (or prominence of the right outflow tract) on chest
roentgenogram or fluoroscopy; AND
-
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:
-
A.
Treadmill exercise test (see 4.00F and G) demonstrating one of the following at an
exercise level of 5 METs or less:
-
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.
Premature ventricular systoles which are multiform or bidirectional or are sequentially
inscribed (3 or more); OR
-
3.
ST segment elevation to 3 mm. or greater; OR
-
4.
Development of second or third degree heart block; OR
-
B.
In the absence of a report of an acceptable treadmill exercise test (see 4.00G), one
of the following:
-
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.
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.
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.
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.
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.
“Double” Master Two-Step test demonstrating one of the following:
-
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
-
b.
Development of a second or third degree heart block; OR
-
7.
Angiographic evidence (see 4.00H) (obtained independent of Social Security disability
evaluation) showing one of the following:
-
a.
50 percent or more narrowing of the left main coronary artery; OR
-
b.
70 percent or more narrowing of a proximal coronary artery (see 4.00H3) (excluding
the left main coronary artery); OR
-
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
-
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:
-
A.
Acute or chronic dissection not controlled by prescribed medical or surgical treatment;
OR
-
B.
Congestive heart failure as described under the criteria in 4.02; OR
-
C.
Renal failure as described under the criteria in 6.02; OR
-
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:
-
A.
Intermittent claudication with failure to visualize (on arteriogram obtained independent
evaluation) the common femoral or deep femoral artery in one extremity; OR
-
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
-
C.
Amputation at or above the tarsal region due to peripheral vascular disease.
5.00 Digestive System
-
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.
-
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.
-
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:
-
A.
Recurrent ulceration after definitive surgery persistent despite therapy; OR
-
B.
Inoperable fistula formation; OR
-
C.
Recurrent obstruction demonstrated by X-ray or endoscopy; OR
-
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:
-
A.
Esophageal varices (demonstrated by X-ray or endoscopy) with a documented history
of massive hemorrhage attributable to these varices; OR
-
B.
Performance of a shunt operation for esophageal varices; OR
-
C.
Serum bilirubin of 2.5 mg. per deciliter (100 ml.) or greater persisting on repeated
examinations for at least 5 months; OR
-
D.
Hepatic encephalopathy. Evaluate under the criteria in 12.02; OR
-
E.
Confirmation of chronic liver disease by liver biopsy (obtained independent of Social
Security disability evaluation) and one of the following:
-
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.
Serum bilirubin of 2.5 mg. per deciliter (100 ml.) or greater on repeated examinations
for at least 3 months; OR
-
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:
-
A.
Recurrent bloody stools documented on repeated examinations and anemia manifested
by hematocrit of 30 percent or less on repeated examinations; OR
-
B.
Persistent or recurrent systemic manifestations, such as arthritis, iritis, fever,
or liver dysfunction, not attributable to other causes; OR
-
C.
Intermittent obstruction due to intractable abscess, fistula formation, or stenosis;
OR
-
D.
Recurrences of findings of A, B, or C above after total colectomy; OR
-
E.
Weight loss as described under 5.08.
5.07 Regional Enteritis
Demonstrated by operative findings, barium studies, biopsy, or endoscopy, with:
-
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
-
B.
Persistent or recurrent systemic manifestations such as arthritis, iritis, fever,
or liver dysfunction, not attributable to other causes; OR
-
C.
Intermittent obstruction due to intractable abscess or fistula formation; OR
-
D.
Weight loss as described under 5.08.
5.08 Weight Loss
Due to any gastrointestinal disorder, with:
-
A.
Weight equal to or less than the values specified in table I or II; OR
-
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.
Serum albumin of 3.0 gm. per deciliter (100 ml.) or less; OR
-
2.
Hematocrit of 30 percent or less; OR
-
3.
Serum calcium of 8.0 mg. per deciliter (100 ml.) (4.0 mEq./L) or less; OR
-
4.
Uncontrolled diabetes mellitus due to pancreatic dysfunction with repeated hyperglycemia,
hypoglycemia, or ketosis; OR
-
5.
Fat in stool of 7 gm. or greater per 24-hour stool specimen; OR
-
6.
Nitrogen in stool of 3 gm. or greater per 24-hour specimen; OR
-
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.
Table I—Men
Height (inches) 1 |
Weight (pounds) |
|
61 |
90 |
|
62 |
92 |
|
63 |
94 |
|
64 |
97 |
|
65 |
99 |
|
66 |
102 |
|
67 |
106 |
|
68 |
109 |
|
69 |
112 |
|
70 |
115 |
|
71 |
118 |
|
72 |
122 |
|
73 |
125 |
|
74 |
128 |
|
75 |
131 |
|
76 |
134 |
|
1 Height measured without shoes.
Table II—Women
Height (inches) 1 |
Weight (pounds) |
|
58 |
77 |
|
59 |
79 |
|
60 |
82 |
|
61 |
84 |
|
62 |
86 |
|
63 |
89 |
|
64 |
91 |
|
65 |
94 |
|
66 |
98 |
|
67 |
101 |
|
68 |
104 |
|
69 |
107 |
|
70 |
110 |
|
71 |
114 |
|
72 |
117 |
|
73 |
120 |
|
1 Height measured without shoes.
Table III—Men
Height (inches) 1 |
Weight (pounds) |
|
61 |
95 |
|
62 |
98 |
|
63 |
100 |
|
64 |
103 |
|
65 |
106 |
|
66 |
109 |
|
67 |
112 |
|
68 |
116 |
|
69 |
119 |
|
70 |
122 |
|
71 |
126 |
|
72 |
129 |
|
73 |
133 |
|
74 |
136 |
|
75 |
139 |
|
76 |
143 |
|
1 Height measured without shoes.
Table IV—Women
Height (inches) 1 |
Weight (pounds) |
|
58 |
82 |
|
59 |
84 |
|
60 |
87 |
|
61 |
89 |
|
62 |
92 |
|
63 |
94 |
|
64 |
97 |
|
65 |
100 |
|
66 |
104 |
|
67 |
107 |
|
68 |
111 |
|
69 |
114 |
|
70 |
117 |
|
71 |
121 |
|
72 |
124 |
|
73 |
128 |
|
1 Height measured without shoes.
6.00 Genito-Urinary System
-
A.
Determination of the presence of chronic renal disease
Determination of the presence of chronic renal disease will be based upon
-
1.
A history, physical examination, and laboratory evidence of renal disease, and
-
2.
Indications of its progressive nature or laboratory evidence of deterioration of renal
function.
-
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.
-
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.
-
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:
-
A.
Chronic hemodialysis or peritoneal dialysis necessitated by irreversible renal failure;
OR
-
B.
Kidney transplant. Consider under a disability for 12 months following surgery; thereafter,
evaluate the residual impairment (see 6.00C); OR
-
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.
Renal osteodystrophy manifested by severe bone pain and appropriate radiographic abnormalities
(e.g., osteitis fibrosa, marked osteoporosis, pathologic fractures); OR
-
2.
A clinical episode of pericarditis; OR
-
3.
Persistent motor or sensory neuropathy; OR
-
-
5.
Persistent fluid overload syndrome resulting in diastolic hypertension (110 mm. or
above) or signs of vascular congestion; OR
-
6.
Persistent anorexia with recent weight loss and current weight meeting the values
in 5.08, table III or IV; OR
-
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:
-
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
-
B.
Proteinuria of 10.0 gm. per 24 hours or greater.
7.00 Hemic and Lymphatic System
-
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.
-
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.
-
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.
-
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.
-
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).
-
A.
Evaluate the resulting impairment under criteria for the affected body system.
-
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:
-
A.
Documented painful (thrombotic) crises occurring at least three times during the 5
months prior to adjudication; OR
-
B.
Requiring extended hospitalization (beyond emergency care) at least three times during
the 12 months prior to adjudication; OR
-
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:
-
A.
At least one spontaneous hemorrhage, requiring transfusion, within 5 months prior
to adjudication; OR
-
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:
-
A.
Chronic anemia. Evaluate according to the criteria of 7.02; OR
-
B.
Documented recurrent systemic bacterial infections occurring at least 3 times during
the 5 months prior to adjudication; OR
-
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:
-
A.
Absolute neutrophil counts repeatedly below 1,000 cells/cubic millimeter; AND
-
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:
-
A.
Radiologic evidence of bony involvement with intractable bone pain; OR
-
B.
Evidence of renal impairment as described in 6.02; OR
-
C.
Hypercalcemia with serum calcium levels persistently greater than 11 mg. per deciliter
(100 ml.) for at least 1 month despite prescribed therapy; OR
-
D.
Plasma cells (100 or more cells/cubic millimeter) in the peripheral blood.
8.00 Skin
-
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.
-
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:
-
A.
Progressive exophthalmos as measured by exophthalmometry; OR
-
B.
Evaluate the resulting impairment under the criteria for the affected body system.
9.03 Hyperparathyroidism
With:
-
A.
Generalized decalcification of bone on X-ray study and elevation of plasma calcium
to 11 mg. per deciliter (100 ml.) or greater; OR
-
B.
Evaluate the resulting impairment according to the listing under the affected body
system.
9.04 Hypoparathyroidism
With:
-
A.
Severe recurrent tetany; OR
-
B.
Recurrent generalized convulsions; OR
-
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:
-
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
-
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
-
C.
Amputation at, or above, the tarsal region due to diabetic necrosis or peripheral
arterial disease; OR
-
D.
Retinitis proliferans; evaluate the visual impairment under the criteria in 2.02,
2.03, or 2.04.
10.00 Multiple Body Systems
-
A.
General
The impairments included in this section usually involve more than a single body system.
-
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:
-
A.
Advanced limitation of use of hands due to sclerodactylia or limitation in other joints;
OR
-
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:
-
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
-
B.
Hypertension with diastolic blood pressure persistently in excess of 100 mm. Hg measured
with appropriate size cuff; OR
-
C.
History of congestive heart failure manifested by past evidence of vascular congestion
such as hepatomegaly, peripheral or pulmonary edema; OR
-
D.
Chronic venous insufficiency with superficial varicosities in a lower extremity with
pain on weight bearing and persistent edema; OR
-
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:
Arterial pCO2 (mm. Hg) AND |
Arterial pO2 equal to or less than (mm. Hg) |
30 or below |
65 |
31 |
64 |
32 |
63 |
33 |
62 |
34 |
61 |
35 |
60 |
36 |
59 |
37 |
58 |
38 |
57 |
39 |
56 |
40 or above |
55 |
Table I—Men
Height Without Shoes (inches) |
Weight (pounds) |
60 |
246 |
61 |
252 |
62 |
258 |
63 |
264 |
64 |
270 |
65 |
276 |
66 |
284 |
67 |
294 |
68 |
302 |
69 |
310 |
70 |
318 |
71 |
328 |
72 |
336 |
73 |
346 |
74 |
356 |
75 |
364 |
76 |
374 |
Table II—Women
Height Without Shoes (inches) |
Weight (pounds) |
56 |
208 |
57 |
212 |
58 |
218 |
59 |
224 |
60 |
230 |
61 |
236 |
62 |
242 |
63 |
250 |
64 |
258 |
65 |
266 |
66 |
274 |
67 |
282 |
68 |
290 |
69 |
298 |
70 |
306 |
71 |
314 |
72 |
322 |
11.00 Neurological
-
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.
-
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).
-
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.
-
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:
-
A.
Diurnal episodes (loss of consciousness and convulsive seizures); OR
-
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:
-
A.
Sensory or motor aphasia resulting in ineffective speech or communication; OR
-
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
-
A.
Malignant gliomas (astrocytoma—grades III and IV, glioblastoma multi- forme), medulloblastoma,
ependymoblastoma, or primary sarcoma; OR
-
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:
-
-
B.
Abnormal behavior patterns, such as destructiveness or emotional instability; OR
-
C.
Significant interference in communication due to speech, hearing, or visual defect;
OR
-
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:
-
A.
Disorganization of motor function as described in 11.04B; OR
-
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:
-
A.
Significant bulbar signs; OR
-
B.
Disorganization of motor function as described in 11.04B.
11.11 Anterior Poliomyelitis
With:
-
A.
Persistent difficulty with swallowing or breathing; OR
-
B.
Unintelligible speech; OR
-
C.
Disorganization of motor function as described in 11.04B.
11.12 Myasthenia Gravis
With:
-
A.
Significant difficulty with speaking, swallowing, or breathing while on prescribed
therapy; OR
-
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:
-
A.
Tabetic crises occurring more frequently than once monthly; OR
-
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:
-
A.
Disorganization of motor function as described in 11.04B or 11.15B; OR
-
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:
-
A.
Significant bulbar signs; OR
-
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
-
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.
-
B.
Discussion of mental disorders
-
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.
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.
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).
-
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).
-
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.
-
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.
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:
-
A.
Demonstrated deterioration in intellectual functioning, manifested by persistence
of one or more of the following clinical signs:
-
1.
Marked memory defect for recent events; OR
-
2.
Impoverished, slowed, perseverative thinking, with confusion or disorientation; OR
-
3.
Labile, shallow, or coarse affect;
-
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:
-
A.
Manifested persistence of one or more of the following clinical signs:
-
1.
Depression (or elation); OR
-
-
3.
Psychomotor disturbances; OR
-
4.
Hallucinations or delusions; OR
-
5.
Autistic or other regressive behavior; OR
-
6.
Inappropriateness of affect; OR
-
7.
Illogical association of ideas;
-
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:
-
A.
Manifested persistence of one or more of the following clinical signs:
-
1.
Demonstrable and persistent structural changes mediated through psychophysiological
channels (e.g., duodenal ulcer); OR
-
2.
Recurrent and persistent periods of anxiety, with tension, apprehension, and interference
with concentration and memory; OR
-
3.
Persistent depressive affect with insomnia, loss of weight, and suicidal preoccupation;
OR
-
4.
Persistent phobic or obsessive ruminations with inappropriate, bizarre, or disruptive
behavior; OR
-
5.
Persistent compulsive, ritualistic behavior; OR
-
6.
Persistent functional disturbance of vision, speech, hearing, or use of a limb with
demonstrable structural or trophic changes; OR
-
7.
Persistent deeply ingrained, maladaptive patterns of behavior manifested by either:
-
a.
Seclusiveness or autistic thinking; OR
-
b.
Pathologically inappropriate suspiciousness or hostility;
-
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:
-
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
-
B.
IQ of 59 or less (see 12.00B4); OR
-
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
-
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.
-
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.
-
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.
-
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.
-
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):
-
-
B.
Not controlled by prescribed therapy; OR
-
C.
Recurrent after radical surgery or irradiation; OR
-
D.
With distant metastases; OR
-
E.
Epidermoid carcinoma occurring in the pyriform sinus or posterior third of the tongue.
13.03 SARCOMA OF SKIN
-
A.
Angiosarcoma with metastases to regional lymph nodes or beyond; OR
-
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:
-
A.
Recurrent after wide excision; OR
-
B.
With metastases to adjacent skin (satellite lesions) or elsewhere.
13.06 Lymph Nodes:
-
A.
Hodgkin's disease or non-Hodgkin's lymphoma with progressive disease not controlled
by prescribed therapy; OR
-
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
-
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
-
-
B.
Inflammatory carcinoma; OR
-
C.
Recurrent carcinoma, except local recurrence controlled by prescribed therapy; OR
-
D.
Distant metastases from breast carcinoma (bilateral breast carcinoma, synchronous
or metachronous, is usually primary in each breast); OR
-
E.
Sarcoma with metastases anywhere.
13.10 Skeletal system (exclusive of the jaw):
-
A.
Malignant primary tumors with evidence of metastases and not controlled by prescribed
therapy; OR
-
B.
Metastatic carcinoma to bone where the primary site is not determined after adequate
search.
13.11 Mandible, Maxilla, Orbit, or Temporal Fossa
-
A.
Sarcoma of any type with metastases; OR
-
B.
Carcinoma of the antrum with extension into the orbit or ethmoid or sphenoid sinus,
or with regional or distant metastases; OR
-
C.
Orbital tumors with intracranial extension; OR
-
D.
Tumors of the temporal fossa with perforation of skull and meningeal involvement;
OR
-
E.
Adamantinoma with orbital or intracranial infiltration; OR
-
F.
Tumors of Rathke's pouch with infiltration of the base of the skull or metastases.
13.12 Brain or Spinal Cord
-
A.
Metastatic carcinoma to brain or spinal cord.
-
B.
Evaluate other tumors under the criteria described in 11.05 and 11.08.
13.13 Lungs
-
-
-
C.
Recurrent after resection; OR
-
-
13.14 Pleura or Mediastinum
-
A.
Malignant mesothelioma of pleura; OR
-
B.
Malignant tumors, metastatic to pleura; OR
-
C.
Malignant primary tumor of the mediastinum not controlled by prescribed therapy.
13.15 Abdomen:
-
A.
Generalized carcinomatosis; OR
-
B.
Retroperitoneal cellular sarcoma not controlled by prescribed therapy; OR
-
C.
Ascites with demonstrated malignant cells.
13.16 Esophagus or Stomach
-
A.
Carcinoma or sarcoma of the upper two-thirds of the esophagus; OR
-
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
-
C.
Carcinoma of the stomach with mestasis to the regional lymph nodes or extension to
surrounding structures; OR
-
D.
Sarcoma of stomach not controlled by prescribed therapy; OR
-
-
F.
Recurrence or metastases after resection.
13.17 Small Intestine:
-
A.
Carcinoma, sarcoma, or carcinoid tumor with metastases beyond the regional lymph nodes;
OR
-
B.
Recurrence of carcinoma, sarcoma, or carcinoid tumor after resection; OR
-
C.
Sarcoma, not controlled by prescribed therapy.
13.18 Large Intestine (From Ileocecal Valve to and Including Anal Canal) - CARCINOMA
OR SARCOMA
-
-
B.
Metastases beyond the regional lymph nodes; OR
-
C.
Recurrence or metastases after resection.
13.19 Liver or Gallbladder
-
A.
Primary or metastatic malignant tumors of the liver; OR
-
B.
Carcinoma of the gallbladder; OR
-
C.
Carcinoma of the bile ducts, unresectable or with metastases.
313.20 Pancreas
-
A.
Carcinoma except islet cell carcinoma; OR
-
B.
Islet cell carcinoma which is unresectable and physiologically active.
13.21 Kidneys, Adrenal Glands, or Ureters—Carcinoma
-
-
13.22 Urinary Bladder—Carcinoma
With:
-
A.
Infiltration beyond the bladder wall; OR
-
-
-
D.
Recurrence after total cystectomy; OR
-
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
-
-
B.
Other malignant primary tumors with progressive disease not controlled by prescribed
therapy.
13.25 Uterus—Carcinoma or Sarcoma (Corpus or Cervix):
-
A.
Inoperable and not controlled by prescribed therapy; OR
-
B.
Recurrent after total hysterectomy; OR
-
C.
Total pelvic exenteration.
13.26 Ovaries
All malignant primary or recurrent tumors.
With:
-
A.
Ascites with demonstrated malignant cells; OR
-
B.
Unresectable infiltration; OR
-
C.
Unresectable metastases to omentum or elsewhere in the peritoneal cavity; OR
-
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.