TN 5 (10-23)
DI 34221.017 Musculoskeletal Listings from 07/23/21 to 10/29/23
101.00 Musculoskeletal Disorders
A. Which musculoskeletal disorders do we evaluate under these listings?
1. We evaluate disorders of the skeletal spine (vertebral column) or of the upper
or lower extremities that affect musculoskeletal functioning under these listings.
We use the term “skeletal” when we are referring to the structure of the bony skeleton.
The skeletal
spine refers to the bony structures, ligaments, and discs making up the spine. We refer
to the skeletal spine in some musculoskeletal listings to differentiate it from the
neurological spine (see 101.00B1). Musculoskeletal disorders may be congenital or acquired, and may
include deformities, amputations, or other abnormalities. These disorders may involve
the bones or major joints; or the tendons, ligaments, muscles, or other soft tissues.
2. We evaluate soft tissue injuries (including burns) or abnormalities that are under
continuing surgical management (see 101.00P1). The injuries or abnormalities may affect
any part of the body, including the face and skull.
3. We evaluate curvatures of the skeletal spine that affect musculoskeletal functioning
under 101.15. If a curvature of the skeletal spine is under continuing surgical management
(see 101.00P1), we will evaluate it under 101.21 using our rules for determining medical
equivalence. See § 416.926 of this chapter.
B. Which related disorders do we evaluate under other listings?
1. We evaluate a disorder or injury of the skeletal spine that results in damage to,
and neurological dysfunction of, the spinal cord and its associated nerves (for example,
paraplegia or quadriplegia) under the listings in 111.00.
2. We evaluate inflammatory arthritis (for example, rheumatoid arthritis) under the
listings in 114.00.
3. We evaluate curvatures of the skeletal spine that interfere with your ability to
breathe under the listings in 103.00, impair myocardial function under the listings
in 104.00, or result in social withdrawal or depression under the listings in 112.00.
4. We evaluate non-healing or pathological fractures due to cancer, whether it is
a primary site or metastases, under the listings in 113.00.
5. We evaluate the leg pain associated with peripheral vascular claudication under
the listings in 104.00.
6. We evaluate burns that do not require continuing surgical management under the
listings in 108.00.
C. What evidence do we need to evaluate your musculoskeletal disorder?
1. General. We need objective medical evidence from an acceptable medical source to establish
that you have a medically determinable musculoskeletal disorder. We also need evidence
from both medical and nonmedical sources, who can describe how you function, to assess
the severity and duration of your musculoskeletal disorder. We will determine the
extent and kinds of evidence we need from medical and nonmedical sources based on
the individual facts about your disorder. For our basic rules on evidence, see §§416.912,
416.913, and 416.920(b) of this chapter. For our rules on evidence about your symptoms,
see §416.929 of this chapter.
2. Physical examination report(s). In the report(s) of your physical examination, we require a medical source’s detailed
description of the orthopedic, neurologic, or other objective clinical findings appropriate
to your specific musculoskeletal disorder from his or her direct observations during
your physical examination. We will not accept a report of your statements about your
symptoms and limitations in place of the medical source’s report of objective clinical
findings. We will not use findings on imaging or other diagnostic tests (see 101.00C3)
as a substitute for findings on physical examination.
a. When the medical source reports that a clinical test sign(s) is positive, unless
we have evidence to the contrary, we will assume that he or she performed the test
properly and accept the medical source’s interpretation of the test. For example,
we will assume a straight-leg raising test was conducted properly (that is, in sitting
and supine positions), even if the medical source does not specify the positions in
which the test was performed.
b. If you use an assistive device (see 101.00C6), the report must support the medical
need for the device.
c. If your musculoskeletal disorder causes a reduction in muscle strength, the report
must document measurement of the strength of the muscle(s) in question. The measurement
should be based on a muscle strength grading system that is considered medically acceptable
based on your age and impairments. For example, a grading system of 0 to 5, with 0
indicating complete loss of strength and 5 indicating maximum strength or equivalent
medically acceptable scale (see Table 1). Reduction in muscle strength is demonstrated
by evidence that your muscle strength is less than active range of motion (ROM) against
gravity with maximum resistance. If the reduction in muscle strength involves one
or both of your hands, the report must also document measurements of grip and pinch
strength.
Table 1 – Grading System of Muscle Function
|
Grade
|
Function of the Muscle
|
|
0
|
None
|
No visible or palpable contraction.
|
|
1
|
Trace
|
Visible or palpable contraction with no motion.
|
|
2
|
Poor
|
Active ROM with gravity eliminated.
|
|
3
|
Fair
|
Active ROM against gravity only, without resistance.
|
|
4
|
Good
|
Active ROM against gravity, moderate resistance.
|
|
5
|
Normal
|
Active ROM against gravity, maximum resistance.
|
3. Imaging and other diagnostic tests.
a. Imaging refers to medical imaging techniques, such as x-ray, computed tomography (CT), magnetic
resonance imaging (MRI), and radionuclide scanning. For the purpose of these listings,
the imaging must be consistent with the prevailing state of medical knowledge and
clinical practice as the proper technique to support the evaluation of the disorder.
b. Findings on imaging must have lasted, or be expected to last, for a continuous
period of at least 12 months.
c. Imaging and other diagnostic tests can provide evidence of physical abnormalities;
however, these abnormalities may correlate poorly with your symptoms, including pain,
or with your musculoskeletal functioning. Accordingly, we will not use findings on
imaging or other diagnostic tests as a substitute for findings on physical examination
about your ability to function, nor can we infer severity or functional limitations
based solely on such tests.
d. For our rules on purchasing imaging and other diagnostic tests, see §§416.919k
and 416.919(m) of this chapter.
4. Operative reports. If you have had a surgical procedure, we need a copy of the operative report, including
details of the findings at surgery and information about any medical complications
that may have occurred. If we do not have the operative report, we need confirmatory
evidence of the surgical procedure from a medical source (for example, detailed follow-up
reports or notations in the medical records concerning the surgical procedure in your
medical history).
5. Effects of treatment.
a. General. Treatments for musculoskeletal disorders may have beneficial or adverse effects,
and responses to treatment vary from person to person. We will evaluate all of the
effects of treatment (including surgical treatment, medications, and therapy) on the
symptoms, signs, and laboratory findings of your musculoskeletal disorder, and on
your musculoskeletal functioning.
b. Response to treatment. To evaluate your musculoskeletal functioning in response to treatment, we need the
following: A description, including the frequency of the administration, of your medications;
the type and frequency of therapy you receive; and a description of your response
to treatment and any complications you experience related to your musculoskeletal
disorder. The effects of treatment may be temporary or long-term. We need information
over a sufficient period to determine the effects of treatment on your current musculoskeletal
functioning and permit reasonable projections about your future functioning. We will
determine the amount of time that constitutes a sufficient period in consultation
with a medical consultant on a case by case basis. In some cases, we will need additional
evidence to make an assessment about your response to treatment. Your musculoskeletal
disorder may meet or medically equal one of these listings regardless of whether you
were prescribed opioid medication, or whether you were prescribed opioid medication
and did not follow this prescribed treatment.
6. Assistive devices.
a. General. An assistive device, for the purposes of these listings, is any device that you use
to improve your stability, dexterity, or mobility. An assistive device can be worn
(see 101.00C6b and 101.00C6c), hand-held (see 101.00C6d), or used in a seated position
(see 101.00C6e). When we use the phrase “documented medical need,” we mean that there
is evidence from a medical source that supports your medical need for an assistive
device (see 101.00C2b) for a continuous period of at least 12 months (see 101.00c2a).
This evidence must describe any limitation(s) in your upper or lower extremity functioning
and the circumstances for which you need to use the assistive device. We do not require
that you have a specific prescription for the assistive device.
b. Prosthesis(es). A prosthesis is a wearable device, such as an artificial limb, that takes the place
of an absent body part. If you have a prosthesis(es), we need evidence from a medical
source documenting your ability to walk, or perform fine and gross movements (see
101.00E4), with the prosthesis(es) in place. When amputation(s) involves one or both
lower extremities, it is not necessary for the medical source to evaluate your ability
to walk without the prosthesis(es) in place. If you cannot use your prosthesis(es)
due to complications affecting your residual limb(s), we need evidence from a medical
source documenting the condition of your residual limb(s) and the medical basis for
your inability to use the device(s).
c. Orthosis(es). An orthosis is a wearable device, such as a brace, that prevents or corrects a dysfunction
or deformity by aligning or supporting the affected body part. If you have an orthosis(es),
we need evidence from a medical source documenting your ability to walk, or perform
fine and gross movements (see 101.00E4), with the orthosis(es) in place. If you cannot
use your orthosis(es), we need evidence from a medical source documenting the medical
basis for your inability to use the device(s).
d. Hand-held assistive devices. Hand-held assistive devices include walkers, canes, or crutches, which you hold onto
with your hand(s) to support or aid you in walking. When you use a one-handed, hand-held
assistive device (such as a cane) with one upper extremity to walk and you cannot
use your other upper extremity for fine or gross movements (see 101.00E4), the need
for the assistive device limits the use of both upper extremities. If you use a hand-held
assistive device, we need evidence from a medical source describing how you walk with
the device.
e. Wheeled and seated mobility devices. Wheeled and seated mobility devices are assistive devices that you use in a seated
position, such as manual wheelchairs, motorized wheelchairs, rollators, and power
operated vehicles. If you use a wheeled and seated mobility device, we need evidence
from a medical source describing the type of wheeled and seated mobility device that
you use and how you use the assistive device, including any customizations or modifications
to the assistive device itself or for your use of the assistive device. For example,
if you use a wheelchair that typically requires the use of both hands but has been
customized for your use with one hand, then we will evaluate your use of the assistive
device using the criteria in 101.00E3b and not 101.00E3a.
(i) Wheeled and seated mobility devices involving the use of both hands. Some wheeled and seated mobility devices involve the use of both hands to use the
assistive device (for example, most manual wheelchairs). If you use a wheeled and
seated mobility device that involves the use of both hands, then the need for the
assistive device limits the use of both upper extremities.
(ii) Wheeled and seated devices involving the use of one hand. Some wheeled and seated mobility devices involve the use of one hand to use the assistive
device (for example, most motorized wheelchairs). If you use a wheeled and seated
mobility device that involves the use of one upper extremity and you cannot use your
other upper extremity for fine or gross movements (see 101.00E4), then the need for
the assistive device limits the use of both upper extremities
7. Longitudinal evidence.
a. The term pandemic period as used in 101.00C7c means the period beginning on April 2, 2021, and ending on the
date that is 6 months after the effective date of a determination by the Secretary
of Health and Human Services under section 319 of the Public Health Service Act, 42
U.S.C. 247d, that the national public health emergency resulting from the COVID-19
pandemic no longer exists.
b. We generally need a longitudinal medical record to assess the severity and duration
of your musculoskeletal disorder because the severity of symptoms, signs, and laboratory
findings related to most musculoskeletal disorders may improve over time or respond
to treatment. Evidence over an extended period will show whether your musculoskeletal
functioning is improving, worsening, or unchanging.
c. For 101.15, 101.16, 101.17, 101.18, 101.20C, 101.20D, 101.22, and 101.23, all of
the required criteria must be present simultaneously, or within a close proximity
of time, to satisfy the level of severity needed to meet the listing. The phrase “within
a close proximity of time” means that all of the relevant criteria must appear in the medical record within a consecutive 4-month
period, except for claims determined or decided during the pandemic period. For claims determined or decided during the pandemic
period, all of the relevant criteria must appear in the medical record within a consecutive
12-month period. When the criterion is imaging, we mean that we could reasonably expect
the findings on imaging to have been present at the date of impairment or date of
onset. For listings that use the word “and” to link the elements of the required criteria,
the medical record must establish the simultaneous presence, or presence within a
close proximity of time, of all the required medical criteria. Once this level of
severity is established, the medical record must also show that this level of severity
has continued, or is expected to continue, for a continuous period of at least 12
months.
8. Surgical treatment or physical therapy. For some musculoskeletal disorders, a medical source may recommend surgery, or physical
therapy (PT). If you have not yet had the recommended surgery or PT, we will not assume
that these interventions will resolve your disorder or improve your functioning. We
will assess each case on an individual basis. Depending on your response to treatment,
or your medical sources’ treatment plans, we may defer our findings regarding the
effect of surgery or PT, until a sufficient period has passed to permit proper consideration
or judgment about your future functioning. When necessary, we will follow the rules
on following prescribed treatment in §416.930 of this chapter, including consideration
of your reasons for failure to follow prescribed treatment.
D. How do we consider symptoms, including pain, under these listings?
1. Musculoskeletal disorders may cause pain or other symptoms; however, your statements
about your pain or other symptoms will not alone establish that you are disabled.
We will not substitute an alleged or a reported increase in the intensity of a symptom,
such as pain, no matter how severe, for a medical sign or diagnostic finding present
in the listing criteria. Pain is included as just one consideration in 101.15A, 101.16A,
and 101.18A, but it is not required to satisfy the criteria in 101.15, 101.16, and
101.18.
2. To consider your symptom(s), we require objective medical evidence from an acceptable
medical source showing the existence of a medically determinable musculoskeletal impairment
that we could reasonably expect to produce the symptom(s). See §416.929 of this chapter
for how we evaluate symptoms, including pain, related to your musculoskeletal disorder.
E. How do we use the functional criteria to evaluate your musculoskeletal disorder under
these listings?
1. General. The functional criteria for children age 3 and older are based on impairment-related
physical limitations in your ability to use both upper extremities, one or both lower
extremities, or a combination of one upper and one lower extremity. We will use the
relevant evidence that we have to compare your musculoskeletal functioning to the
functioning of children your age who do not have impairments. The required impairment-related
physical limitation of musculoskeletal functioning must have lasted, or be expected
to last, for a continuous period of at least 12 months. We do not use the functional
criteria in 101.20A, 101.20B, 101.21, or 101.24.
2. Medical and functional criteria, birth to attainment of age 3. The medical and functional criteria for children in this age group are in 101.24.
3. Functional criteria, age 3 to attainment of age 18. The functional criteria are based on impairment-related physical limitations in
your ability to use both upper extremities, one or both lower extremities, or a combination
of one upper and one lower extremity. A musculoskeletal disorder satisfies the functional
criteria of a listing when the medical documentation shows the presence of at least
one of the impairment-related limitations cited in the listing. The functional criteria
require impairment-related physical limitation of musculoskeletal functioning that
has lasted, or can be expected to last, for a continuous period of at least 12 months,
medically documented by one of the following:
a. A documented medical need (see 101.00C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i));
b. An inability to use one upper extremity to independently initiate, sustain, and
complete age-appropriate activities involving fine and gross movements (see 101.00E4),
and a documented medical need (see 101.00C6a) for a one-handed, hand-held assistive
device (see 101.00C6d) that requires the use of your other upper extremity or a wheeled
and seated mobility device involving the use of one hand (see 101.00C6e(ii));
c. An inability to use both upper extremities to the extent that neither can be used
to independently initiate, sustain, and complete age-appropriate activities involving
fine and gross movements (see 101.00E4).
4. Fine and gross movements. Fine movements, for the purposes of these listings, involve use of your wrists, hands,
and fingers; such movements include picking, pinching, manipulating, and fingering.
Gross movements involve use of your shoulders, upper arms, forearms, and hands; such movements
include handling, gripping, grasping, holding, turning, and reaching. Gross movements
also include exertional abilities such as lifting, carrying, pushing, and pulling.
F. What do we consider when we evaluate disorders of the skeletal spine resulting in
compromise of a nerve root(s) (101.15)?
1. General. We consider musculoskeletal disorders such as skeletal dysplasias, caudal regression
syndrome, tethered spinal cord syndrome, vertebral slippage (spondylolisthesis), scoliosis,
and vertebral fracture or dislocation. Spinal disorders may cause cervical or lumbar
spine dysfunction when abnormalities of the skeletal spine compromise nerve roots
of the cervical spine, a nerve root of the lumbar spine, or a nerve root of both cervical
and lumbar spines. We consider spinal nerve disorders that originate in the nervous
system (for example, spinal arachnoiditis), under the neurological disorders body
system, 111.00.
2. Compromise of a nerve root(s). Compromise of a nerve root, sometimes referred to as “nerve root impingement,” is
a phrase used when a physical object, such as a tumor, herniated disc, foreign body,
or arthritic spur, is pushing on the nerve root as seen on imaging or during surgery.
It can occur when a musculoskeletal disorder produces irritation, inflammation, or
compression of the nerve root(s) as it exits the skeletal spine between the vertebrae.
Related symptoms must be associated with, or follow the path of, the affected nerve
root(s).
a. Compromise of unilateral nerve root of the cervical spine. Compromise of a nerve root as it exits the cervical spine between the vertebrae may
affect the functioning of the associated upper extremity. The physical examination
reproduces the related symptoms based on radicular signs and clinical tests appropriate
to the specific cervical nerve root (for example, a positive Spurling test).
b. Compromise of bilateral nerve roots of the cervical spine. Although uncommon, if compromise of a nerve root occurs on both sides of the cervical
spinal column, functioning of both upper extremities may be limited.
c. Compromise of a nerve root(s) of the lumbar spine. Compromise of a nerve root as it exits the lumbar spine between the vertebrae may
limit the functioning of the associated lower extremity. The physical examination
reproduces the related symptoms based on radicular signs and clinical tests. When
a nerve root of the lumbar spine is compromised, we require a positive straight-leg
raising test (also known as a Lasègue test) in both supine and sitting positions appropriate
to the specific lumbar nerve root that is compromised.
G. What do we consider when we evaluate lumbar spinal stenosis resulting in compromise
of
the cauda equina (101.16)?
1. General. We consider how pain, sensory changes, and muscle weakness caused by compromise of
the cauda equina due to lumbar spinal stenosis affect your functioning. The cauda
equina is a bundle of nerve roots that descends from the lower part of the spinal
cord. Lumbar spinal stenosis can compress the nerves of the cauda equina, causing
sensory changes and muscle weakness that may affect your ability to stand or walk.
Pain related to compromise of the cauda equina is nonradicular because it is not typically
associated with a specific nerve root (as is radicular pain in the cervical or lumbar
spine).
2. Compromise of the cauda equina due to lumbar spinal stenosis can affect your ability to walk or stand because of
neurogenic claudication (also known as pseudoclaudication), a condition usually causing
nonradicular pain that starts in the low back and radiates bilaterally (or less commonly,
unilaterally) into the buttocks and lower extremities (or extremity). Extension of
the lumbar spine, which occurs when you walk or stand, may provoke the pain of neurogenic
claudication. The pain may be relieved by forward flexion of the lumbar spine or by
sitting. In contrast, the leg pain associated with peripheral vascular claudication
results from inadequate arterial blood flow to a lower extremity. It occurs repeatedly
and consistently when a person walks a certain distance and is relieved when the person
rests.
H. What do we consider when we evaluate reconstructive surgery or surgical arthrodesis
of a
major weight-bearing joint (101.17)?
1. General. We consider reconstructive surgery or surgical arthrodesis when an acceptable medical
source(s) documents the surgical procedure(s) and associated medical treatments to
restore function of, or eliminate motion in, the affected major weight-bearing joint(s).
Reconstructive surgery may be done in a single procedure or a series of procedures
directed toward the salvage or restoration of functional use of the affected joint.
2. Major weight-bearing joints are the hip, knee, and ankle-foot. The ankle and foot are considered together as
one major joint.
3. Surgical arthrodesis is the artificial fusion of the bones that form a joint, essentially eliminating
the joint.
I. What do we consider when we evaluate abnormality of a major joint(s) in any extremity
(101.18)?
1. General. We consider musculoskeletal disorders that produce anatomical abnormalities of major
joints of the extremities, which result in functional abnormalities in the upper or
lower extremities (for example, chronic infections of bones and joints, and surgical
arthrodesis of a joint). Abnormalities of the joints include ligamentous laxity or
rupture, soft tissue contracture, or tendon rupture, and can cause muscle weakness
of the affected joint(s).
a. An anatomical abnormality is one that is readily observable by a medical source during a physical
examination (for example, subluxation or contracture), or is present on imaging (for
example, joint space narrowing, bony destruction, ankylosis, or deformity).
b. A functional abnormality is abnormal motion or instability of the affected joint(s), including
limitation of motion, excessive motion (hypermobility), movement outside the normal
plane of motion for the joint (for example, lateral deviation), or fixation of the
affected joint(s).
2. Major joint of an upper extremity refers to the shoulder, elbow, and wrist-hand. We consider the wrist and hand together
as one major joint.
3. Major joint of a lower extremity refers to the hip, knee, and ankle-foot. We consider the ankle and hindfoot together
as one major joint.
J. What do we consider when we evaluate pathologic fractures due to any cause (101.19)?
We consider pathologic fractures of the bones in the skeletal spine, extremities,
or other parts of the skeletal system. Pathologic fractures result from disorders
that weaken the bones, making them vulnerable to breakage. Pathologic fractures may
occur with osteoporosis, osteogenesis imperfecta or any other skeletal dysplasias,
side effects of medications, and disorders of the endocrine or other body systems.
Under 101.19, the fractures must have occurred on separate, distinct occasions, rather
than multiple fractures occurring at the same time, but the fractures may affect the
same bone(s) multiple times. There is no required time that must elapse between the
fractures, but all three must occur within a 12-month period; for example, separate
incidents may occur within hours or days of each other. We evaluate non-healing or
complex traumatic fractures without accompanying pathology under 101.22 or 101.23.
K. What do we consider when we evaluate amputation due to any cause
(101.20)?
1. General. We consider amputation (the full or partial loss or absence of any extremity) due
to any cause including trauma, congenital abnormality or absence, surgery for treatment
of conditions such as cancer or infection, or complications of peripheral vascular
disease or diabetes mellitus.
2. Amputation of both upper extremities (101.20A). Under 101.20A, we consider upper extremity amputations that occur at any level at
or above the wrists (carpal joints), up to and including disarticulation of the shoulder
(glenohumeral) joint. If you have had both upper extremities amputated at any level
at or above the wrists up to and including the shoulder, your impairment satisfies
the duration requirement in § 416.909 of this chapter. For amputations below the wrist,
we will follow the rules described in 101.00R. We do not evaluate amputations below
the wrists under 101.20A because the resulting limitation of function of the thumb(s),
finger(s), or hand(s) will vary, depending on the extent of loss and corresponding
effect on fine and gross movements.
3. Hemipelvectomy or hip disarticulation (101.20B). Under 101.20B, we consider hemipelvectomy, which involves amputation of an entire
lower extremity through the sacroiliac joint, and hip disarticulation, which involves
amputation of an entire lower extremity through the hip joint capsule and closure
of the remaining musculature over the exposed acetabular bone. If you have had a hemipelvectomy
or hip disarticulation, your impairment satisfies the duration requirement in § 416.909
of this chapter.
4. Amputation of one upper extremity and one lower extremity (101.20C). Under 101.20C, we consider the amputation of one upper extremity at any level at
or above the wrist and one lower extremity at or above the ankle. If you have a documented
medical need for a one-handed, hand-held assistive device (such as a cane) or a wheeled
and seated mobility device involving the use of one hand (such as a motorized wheelchair),
then you must use your remaining upper extremity to hold the device, making the extremity
unavailable to perform other fine and gross movements (see 101.00E4).
5. Amputation of one lower extremity or both lower extremities with complications of
the residual limb(s) (101.20D). Under 101.20D, we consider the amputation of one lower extremity or both lower extremities
at or above the ankle. We also consider the condition of your residual limb(s), whether
you can wear a prosthesis(es) (see 101.00C6b), and whether you have a documented medical
need (see 101.00C6a) for a hand-held assistive device(s) (see 101.00C6d) or a wheeled
and seated mobility device (see 101.00C6e). If you have a non-healing residual limb(s)
and are receiving ongoing surgical treatment expected to re-establish or improve function,
and that ongoing surgical treatment has not ended, or is not expected to end, within
at least 12 months of the initiation of the surgical management (see 101.00L), we
evaluate your musculoskeletal disorder under 101.21.
L. What do we consider when we evaluate soft tissue injury or abnormality under continuing
surgical management (101.21)?
1. General.
a. We consider any soft tissue injury or abnormality involving the soft tissues of
the body, whether congenital or acquired, when an acceptable medical source(s) documents
the need for ongoing surgical procedures and associated medical treatments to restore
function of the affected body part(s) (see 101.00P1). Surgical management includes
the surgery(ies) itself, as well as various post-surgical procedures, surgical complications,
infections or other medical complications, related illnesses, or related treatments
that delay your attainment of maximum benefit from therapy (see 101.00P2).
b. Surgical procedures and associated treatments typically take place over extended
periods, which may render you unable to perform age-appropriate activity on a sustained
basis. To document such inability, we must have evidence from an acceptable medical
source(s) confirming that the surgical management has continued, or is expected to
continue, for at least 12 months from the date of the first surgical intervention.
These procedures and treatments must be directed toward saving, reconstructing, or
replacing the affected part of the body to re-establish or improve its function, and
not for cosmetic appearances alone.
c. Examples include malformations, third- and fourth-degree burns, crush injuries,
craniofacial injuries, avulsive injuries, and amputations with complications of the
residual limb(s).
d. We evaluate skeletal spine abnormalities or injuries under 101.15 or 101.16, as
appropriate. We evaluate abnormalities or injuries of bones in the lower extremities
under 101.17, 101.18, or 101.22. We evaluate abnormalities or injuries of bones in
the upper extremities under 101.18 or 101.23.
2. Documentation. In addition to the objective medical evidence we need to establish your soft tissue
injury or abnormality, we also need all of the following medically documented evidence
about your continuing surgical management:
a. Operative reports and related laboratory findings;
b. Records of post-surgical procedures;
c. Records of any surgical or medical complications (for example, related infections
or systemic illnesses);
d. Records of any prolonged post-operative recovery periods and related treatments
(for example, surgeries and treatments for burns);
e. An acceptable medical source’s plans for additional surgeries; and
f. Records detailing any other factors that have delayed, or that an acceptable medical
source expects to delay, the saving, restoring, or replacing of the involved part
for a continuous period of at least 12 months following the initiation of the surgical
management.
3. Burns. Third- and fourth-degree burns damage or destroy nerve tissue, reducing or preventing
transmission of signals through those nerves. Such burns frequently require multiple
surgical procedures and related therapies to re-establish or improve function, which
we evaluate under 101.21. When burns are no longer under continuing surgical
management (see 101.00P1), we evaluate the residual impairment(s). When the residual impairment(s)
affects the musculoskeletal system, as often occurs in third- and fourth-degree burns,
it can result in permanent musculoskeletal tissue loss, joint contractures, or loss
of extremities. We will evaluate such impairments under the relevant musculoskeletal
disorders listing, for example, 101.18 or 101.20. When the residual impairment(s)
involves another body system, we will evaluate the impairment(s) under the listings
in the relevant body system(s).
4. Craniofacial injuries or congenital abnormalities. Surgeons may treat craniofacial injuries or congenital abnormalities with multiple
surgical procedures. These injuries or abnormalities may affect vision, hearing, speech,
and the initiation of the digestive process, including mastication. When the craniofacial
injury-related or congenital abnormality-related residual impairment(s) involves another
body system(s), we will evaluate the impairment(s) under the listings in the relevant
body system(s).
M. What do we consider when we evaluate non-healing or complex fractures of the femur,
tibia, pelvis, or one or more of the talocrural bones (101.22)?
1. Non-healing fracture. A non-healing (nonunion) fracture is a fracture that has failed to unite completely.
Nonunion is usually established when a minimum of 9 months has elapsed since the injury
and the fracture site has shown no, or minimal, progressive signs of healing for a
minimum of 3 months.
2. Complex fracture. A complex fracture is a fracture with one or more of the following:
a. Comminuted (broken into many pieces) bone fragments;
b. Multiple fractures in a single bone;
c. Bone loss due to severe trauma;
d. Damage to the surrounding soft tissue;
e. Severe cartilage damage to the associated joint; or
f. Dislocation of the associated joint.
3. When a complex fracture involves soft tissue damage, the treatment may involve
continuing surgical management to restore or improve functioning. In such cases, we
may evaluate the fracture(s) under 101.21.
N. What do we consider when we evaluate non-healing or complex fractures of an upper
extremity (101.23)?
1. Non-healing fracture. A non-healing (nonunion) fracture is a fracture that has failed to unite completely.
Nonunion is usually established when a minimum of 9 months has elapsed since the injury
and the fracture site has shown no, or minimal, progressive signs of healing for a
minimum of 3 months.
2. Complex fracture. A complex fracture is a fracture with one or more of the following:
a. Comminuted (broken into many pieces) bone fragments;
b. Multiple fractures in a single bone;
c. Bone loss due to severe trauma;
d. Damage to the surrounding soft tissue;
e. Severe cartilage damage to the associated joint; or
f. Dislocation of the associated joint.
3. When a complex fracture involves soft tissue damage, the treatment may involve
continuing surgical management to restore or improve functioning. In such cases, we
may evaluate the fracture(s) under 101.21.
O. What do we consider when we evaluate musculoskeletal disorders of infants and toddlers
from birth to attainment of age 3 with developmental motor delay (101.24)?
1. General. Under 101.24, we require reports from an acceptable medical source(s) to establish
a delay in your motor development as a medically determinable impairment. Examples
of disorders we evaluate under this listing include arthrogryposis, clubfoot, osteogenesis
imperfecta, caudal regression syndrome, fracture complications, disorders affecting
the hip and pelvis, and complications associated with your musculoskeletal disorder
or its treatment. Some medical records may simply document your condition as “developmental
motor delay.”
2. Severity of developmental motor delay. To evaluate the severity of your developmental motor delay, we need developmental
test reports from an acceptable medical source, or from early intervention specialists,
physical and occupational therapists, and other sources.
a. If there is a standardized developmental assessment in your medical record, we
will use the results to evaluate your developmental motor delay under 101.24A. Such
an assessment compares your level of development to the level typically expected for
children of your chronological age. If you were born prematurely, we use your corrected
chronological age for comparison. See § 416.924b(b) of this chapter.
b. If there is no standardized developmental assessment in your medical record, we
will use narrative developmental reports from a medical source(s) to evaluate your
developmental motor delay under 101.24B. These reports must provide detailed information
sufficient for us to assess the severity of your motor delay. If we cannot obtain
sufficient detail from narrative reports, we may purchase standardized developmental
assessments.
(i) A narrative developmental report is based on clinical observations, progress notes,
and well-baby check-ups, and must include your developmental history, examination
findings (with abnormal findings noted on repeated examinations), and an overall assessment
of your development (that is, more than one or two isolated skills) by the medical
source.
(ii) Some narrative developmental reports may include results from developmental screening
tests, which can show that you are not developing or achieving skills within expected
timeframes. Although medical sources may refer to screening test results as supporting
evidence in the narrative developmental report, screening test results alone cannot
establish a medically determinable impairment or the severity of developmental motor
delay.
P. How will we determine whether your soft tissue injury or abnormality or your upper
extremity fracture is no longer under continuing surgical management or you have received
maximum benefit from therapy?
1. We will determine that your soft tissue injury or abnormality, or your upper extremity
fracture, is no longer under continuing surgical management, as used in 101.21 and 101.23, when the last surgical procedure or medical treatment
directed toward the re-establishment or improvement of function of the involved part
has occurred.
2. We will determine that you have received maximum benefit from therapy, as used in 101.21, if there are no significant changes in physical findings or on
appropriate imaging for any 6-month period after the last surgical procedure or medical
treatment. We may also determine that you have received maximum benefit from therapy
if your medical source(s) indicates that further improvement is not expected after
the last surgical procedure or medical treatment.
3. When you have received maximum benefit from therapy, we will evaluate any impairment-related
residual symptoms, signs, and laboratory findings (including those on imaging), any
complications associated with your surgical procedures or medical treatments, and
any residual limitations in your functioning (see 101.00R).
Q. How do we evaluate your musculoskeletal disorder if there is no record of ongoing
treatment?
1. Despite having a musculoskeletal disorder, you may not have received ongoing treatment,
may have just begun treatment, may not have access to prescribed medical treatment,
or may not have an ongoing relationship with the medical community. In any of these
situations, you will not have a longitudinal medical record for us to review when
we evaluate your disorder and we may ask you to attend a consultative examination
to determine the severity and potential duration of your disorder. See § 416.919a(b)
of this chapter.
2. In some instances, we may be able to assess the severity and duration of your musculoskeletal
disorder based on your medical record and current evidence alone. If the information
in your case record is not sufficient to show that you have a musculoskeletal disorder
that meets the criteria of one of the musculoskeletal disorders listings, we will
follow the rules described in 101.00R.
R. How do we evaluate musculoskeletal disorders that do not meet one of these
listings?
1. These listings are only examples of musculoskeletal disorders that we consider
severe enough to result in marked and severe functional limitations. If your impairment(s)
does not meet the criteria of any of these listings, we must also consider whether
you have an impairment(s) that meets the criteria of a listing in another body system.
2. If you have a severe medically determinable impairment(s) that does not meet a
listing, we will determine whether your impairment(s) medically equals a listing.
See §416.926 of this chapter. If your impairment(s) does not meet or medically equal
a listing, we will determine whether it functionally equals the listings. See §416.926a
of this chapter.
3. We use the rules in §416.994a of this chapter when we decide whether you continue
to be disabled.
101.01 Category of Impairments, Musculoskeletal Disorders
101.15 Disorders of the skeletal spine resulting in compromise of a nerve
root(s) (see 101.00F), documented by A, B, C, and D:
A. Neuro-anatomic (radicular) distribution of one or more of the following symptoms consistent with compromise of the affected nerve root(s):
1. Pain; or
2. Paresthesia; or
3. Muscle fatigue.
AND
B. Radicular distribution of neurological signs present during physical examination (see 101.00C2) or on a diagnostic test (see 101.00C3)
and evidenced by 1, 2, and either 3 or 4:
1. Muscle weakness; and
2. Sign(s) of nerve root irritation, tension, or compression, consistent with compromise
of the affected nerve root (see 101.00F2)
3. Sensory changes evidenced by:
a. Decreased sensation; or
b. Sensory nerve deficit (abnormal sensory nerve latency) on electrodiagnostic testing;
or
4. Decreased deep tendon reflexes.
AND
C. Findings on imaging (see 101.00C3) consistent with compromise of a nerve root(s)
in the cervical or lumbosacral spine.
AND
D. Impairment-related physical limitation of musculoskeletal functioning that has lasted,
or is expected to last, for a continuous period of at least 12 months, and medical
documentation of at least one of the following:
1. A documented medical need (see 101.C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i)); or
2. An inability to use one upper extremity to independently initiate, sustain, and complete age-appropriate
activities involving fine and gross movements (see 101.00E4), and a documented medical need (see 101.00C6a) for a one-handed, hand-held assistive device
(see 101.00C6d) that requires the use of the other upper extremity or a wheeled and
seated mobility device involving the use of one hand (see 101.00C6e(ii)); or
3. An inability to use both upper extremities to the extent that neither can be used to independently initiate,
sustain, and complete age-appropriate activities involving fine and gross movements
(see 101.00E4).
101.16 Lumbar spinal stenosis resulting in compromise of the cauda
equina (see 101.00G), documented by A, B, C, and D:
A. Symptom(s) of neurological compromise manifested as:
1. Nonradicular distribution of pain in one or both lower extremities; or
2. Nonradicular distribution of sensory loss in one or both lower extremities; or
3. Neurogenic claudication.
AND
B. Nonradicular neurological signs present during physical examination (see 101.00C2)
or on a diagnostic test (see 101.00C3) and evidenced by 1 and either 2 or 3:
1. Muscle weakness.
2. Sensory changes evidenced by:
a. Decreased sensation; or
b. Sensory nerve deficit (abnormal sensory nerve latency) on electrodiagnostic testing;
or
c. Areflexia, trophic ulceration, or bladder or bowel incontinence.
3. Decreased deep tendon reflexes in one or both lower extremities.
AND
C. Findings on imaging (see 101.00C3) or in an operative report (see 101.00C4) consistent
with compromise of the cauda equina with lumbar spinal stenosis.
AND
D. Impairment-related physical limitation of musculoskeletal functioning that has lasted,
or is expected to last, for a continuous period of at least 12 months, and medical
documentation of at least one of the following:
1. A documented medical need (see 101.00C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i)); or
2. An inability to use one upper extremity to independently initiate, sustain, and complete age-appropriate
activities involving fine and gross movements (see 101.00E4), and a documented medical need (see 101.00C6a) for a one-handed, hand-held assistive device
(see 101.00C6d) that requires the use of the other upper extremity or a wheeled and
seated mobility device involving the use of one hand (see 101.00C6e(ii)).
101.17 Reconstructive surgery or surgical arthrodesis of a major
weight-bearing joint (see 101.00H), documented by A, B, and C:
A. History of reconstructive surgery or surgical arthrodesis of a major weight-bearing
joint.
AND
B. Impairment-related physical limitation of musculoskeletal functioning that has lasted,
or is expected to last, for a continuous period of at least 12 months.
AND
C. A documented medical need (see 101.00C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i)).
101.18 Abnormality of a major joint(s) in any extremity (see 101.00I), documented by A, B, C, and D:
A. Chronic joint pain or stiffness.
AND
B. Abnormal motion, instability, or immobility of the affected joint(s).
AND
C. Anatomical abnormality of the affected joint(s) noted on:
1. Physical examination (for example, subluxation, contracture, or bony or fibrous
ankylosis); or
2. Imaging (for example, joint space narrowing, bony destruction, or ankylosis or
arthrodesis of the affected joint).
AND
D. Impairment-related physical limitation of musculoskeletal functioning that has lasted,
or is expected to last, for a continuous period of at least 12 months, and medical
documentation of at least one of the following:
1. A documented medical need (see 101.00C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i)); or
2. An inability to use one upper extremity to independently initiate, sustain, and complete age-appropriate
activities involving fine and gross movements (see 101.00E4), and a documented medical need (see 101.00C6a) for a one-handed, hand-held assistive device
(see 101.00C6d) that requires the use of the other upper extremity or a wheeled and
seated mobility device involving the use of one hand (see 101.00C6e(ii)); or
3. An inability to use both upper extremities to the extent that neither can be used to independently initiate,
sustain, and complete age-appropriate activities involving fine and gross movements
(see 101.00E4).
101.19 Pathologic fractures due to any cause (see 101.00J), documented by A and B:
A. Pathologic fractures occurring on three separate occasions within a 12-month period.
AND
B. Impairment-related physical limitation of musculoskeletal functioning that has lasted,
or is expected to last, for a continuous period of at least 12 months, and medical
documentation of at least one of the following:
1. A documented medical need (see 101.00C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i)); or
2. An inability to use one upper extremity to independently initiate, sustain, and complete age-appropriate
activities involving fine and gross movements (see 101.00E4), and a documented medical need (see 101.00C6a) for a one-handed, hand-held assistive device
(see 101.00C6d) that requires the use of the other upper extremity or a wheeled and
seated mobility device involving the use of one hand (see 101.00C6e(ii)); or
3. An inability to use both upper extremities to the extent that neither can be used to independently initiate,
sustain, and complete age-appropriate activities involving fine and gross movements
(see 101.00E4).
101.20 Amputation due to any cause (see 101.00K), documented by A, B, C, or D:
A. Amputation of both upper extremities, occurring at any level at or above the wrists
(carpal joints), up to and including the shoulder (glenohumeral) joint.
OR
B. Hemipelvectomy or hip disarticulation.
OR
C. Amputation of one upper extremity, occurring at any level at or above the wrist (carpal
joints), and amputation of one lower extremity, occurring at or above the ankle (talocrural
joint), and medical documentation of at least one of the following:
1. A documented medical need (see 101.00C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i)); or
2. A documented medical need (see 101.00C6a) for a one-handed, hand-held assistive
device (see 101.00C6d) requiring the use of the other upper extremity or a wheeled
and seated mobility device involving the use of one hand (see 101.00C6e(ii)); or
3. The inability to use the remaining upper extremity to independently initiate, sustain,
and complete age-appropriate activities involving fine and gross movements (101.00E4).
OR
D. Amputation of one or both lower extremities, occurring at or above the ankle (talocrural
joint), with complications of the residual limb(s) that have lasted, or are expected
to last, for a continuous period of at least 12 months, and medical documentation of 1 and 2:
1. The inability to use a prosthesis(es); and
2. A documented medical need (see 101.00C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i)).
101.21 Soft tissue injury or abnormality under continuing surgical
management (see 101.00L), documented by A, B, and C:
A. Evidence confirms continuing surgical management (see 101.00P1) directed toward saving,
reconstructing, or replacing the affected part of the body.
AND
B. The surgical management has been, or is expected to be, ongoing for a continuous
period of at least 12 months.
AND
C. Maximum benefit from therapy (see 101.00P2) has not yet been achieved.
101.22 Non-healing or complex fracture of the femur, tibia, pelvis, or one or
more of the talocrural bones (see 101.00M), documented by A, B, and C:
A. Solid union not evident on imaging (see 101.00C3) and not clinically solid.
AND
B. Impairment-related physical limitation of musculoskeletal functioning that has lasted,
or is expected to last, for a continuous period of at least 12 months.
AND
C. A documented medical need (see 101.00C6a) for a walker, bilateral canes, or bilateral
crutches (see 101.00C6d) or a wheeled and seated mobility device involving the use
of both hands (see 101.00C6e(i)).
101.23 Non-healing or complex fracture of an upper extremity (see 101.00N), documented by A and B:
A. Nonunion or complex fracture, of the shaft of the humerus, radius, or ulna, under
continuing surgical management (see 101.00P1) directed toward restoration of functional
use of the extremity.
AND
B. Medical documentation of an inability to independently initiate, sustain, and complete
age-appropriate activities involving fine and gross movements (see 101.00E4) that
has lasted, or is expected to last, for a continuous period of at least 12 months.
101.24 Musculoskeletal disorders of infants and toddlers, from birth to
attainment of age 3, with developmental motor delay (see 101.00O), documented by A or B:
A. A standardized developmental motor assessment that:
1. Shows motor development not more than one-half of the level typically expected
for the child’s age; or
2. Results in a valid score that is at least three standard deviations below the mean.
OR
B. Two narrative developmental reports that:
1. Are dated at least 120 days apart; and
2. Indicate current motor development not more than one-half of the level typically
expected for the child’s age.