1. What evidence do we need?
a. We need evidence showing that you have a medically determinable impairment that
causes your hearing loss and audiometric measurements of the severity of your hearing
loss. We generally require both a complete otologic examination and audiometric testing
to establish that you have a medically determinable impairment that causes your hearing
loss. You should have this audiometric testing within 2 months of the complete otologic
examination. Once we have evidence that you have a medically determinable impairment,
we can use the results of later audiometric testing to assess the severity of your
hearing loss without another complete otologic examination. We will consider your
test scores together with any other relevant information we have about your hearing,
including information from outside of the test setting.
b. The complete otologic examination must be performed by a licensed physician (medical
or osteopathic doctor). It must include your medical history, your description of
how your hearing loss affects you, and the physician's description of the appearance
of the external ears (pinnae and external ear canals), evaluation of the tympanic
membranes, and assessment of any middle ear abnormalities.
c. Audiometric testing must be performed by, or under the direct supervision of, an
otolaryngologist or by an audiologist qualified to perform such tests. We consider
an audiologist to be qualified if he or she is currently and fully licensed or registered
as a clinical audiologist by the State or U.S. territory in which he or she practices.
If no licensure or registration is available, the audiologist must be currently certified
by the American Board of Audiology or have a Certificate of Clinical Competence (CCC-A)
from the American Speech-Language-Hearing Association (ASHA).
2. What audiometric testing do we need when you do not have a cochlear implant?
a. General.
We need either physiologic or behavioral testing (other than screening testing, see
102.00B2g) that is appropriate for your age at the time of testing. See 102.00B2c-102.00B2f.
We will make every reasonable effort to obtain the results of physiologic testing
that has been done; however, we will not purchase such testing.
b. Testing requirements.
The testing must be conducted in accordance with the most recently published standards
of the American National Standards Institute (ANSI). You must not wear hearing aids
during the testing. Additionally, a person described in 102.00B1c must perform an
otoscopic examination immediately before the audiometric testing. (An otoscopic examination
provides a description of the appearance of your external ear canals and an evaluation
of the tympanic membranes. In these rules, we use the term to include otoscopic examinations
performed by physicians and otoscopic inspections performed by audiologists and others.)
The otoscopic examination must show that there are no conditions that would prevent
valid audiometric testing, such as fluid in the ear, ear infection, or obstruction
in an ear canal. The person performing the test should also report on any other factors,
such as your ability to maintain attention, that can affect the interpretation of
the test results.
c. Children from birth to the attainment of age 6 months.
(i) We need physiologic testing, such as auditory brainstem response (ABR) testing.
(ii) To determine whether your hearing loss meets 102.10A, we will average your hearing
thresholds at 500, 1000, 2000, and 4000 Hertz (Hz). If you do not have a response
at a particular frequency, we will use a threshold of 5 decibels (dB) over the limit
of the audiometer.
d. Children from age 6 months to the attainment of age 2.
(i) We need air conduction thresholds determined by a behavioral assessment, usually
visual reinforcement audiometry (VRA). We can use ABR testing if the behavioral assessment
cannot be completed or if the results are inconclusive or unreliable.
(ii) To determine whether your hearing loss meets 102.10A, we will average your hearing
thresholds at 500, 1000, 2000, and 4000 Hz. If you do not have a response at a particular
frequency, we will use a threshold of 5 dB over the limit of the audiometer.
(iii) For this age group, behavioral assessments are often performed in a sound field,
and each ear is not tested separately. If each ear is not tested separately, we will
consider the test results to represent the hearing in the better ear.
e. Children from age 2 to the attainment of age 5.
(i) We need air conduction thresholds determined by a behavioral assessment, such
as conditioned play audiometry (CPA), tangible or visually reinforced operant conditioning
audiometry (TROCA, VROCA), or VRA. If you have had ABR testing, we can use the results
of that testing if the behavioral assessment cannot be completed or the results are
inconclusive or unreliable.
(ii) To determine whether your hearing loss meets 102.10A, we will average your hearing
thresholds at 500, 1000, 2000, and 4000 Hz. If you do not have a response at a particular
frequency, we will use a threshold of 5 dB over the limit of the audiometer.
(iii) For this age group, behavioral assessments are often performed in a sound field
and each ear is not tested separately. If each ear is not tested separately, we will
consider the test results to represent the hearing in the better ear.
f. Children from age 5 to the attainment of age 18.
(i) We generally need pure tone air conduction and bone conduction testing, speech
reception threshold (SRT) testing (also referred to as "spondee threshold'' or "ST''
testing), and word recognition testing (also referred to as "word discrimination''
or "speech discrimination'' testing). This testing must be conducted in a sound-treated
booth or room and must be in accordance with the most recently published ANSI standards.
Each ear must be tested separately.
(ii) To determine whether your hearing loss meets the air and bone conduction criterion
in 102.10B1 or 102.10B3, we will average your hearing thresholds at 500, 1000, 2000,
and 4000 Hz. If you do not have a response at a particular frequency, we will use
a threshold of 5 dB over the limit of the audiometer.
(iii) The SRT is the minimum dB level required for you to recognize 50 percent of
the words on a standard list of spondee words. (Spondee words are two-syllable words
that have equal stress on each syllable.) The SRT is usually within 10 dB of the average
pure tone air conduction hearing thresholds at 500, 1000, and 2000 Hz. If the SRT
is not within 10 dB of the average pure tone air conduction threshold, the reason
for the discrepancy must be documented. If we cannot determine that there is a medical
basis for the discrepancy, we will not use the results of the testing to determine
whether your hearing loss meets a listing.
(iv) Word recognition testing determines your ability to recognize an age-appropriate,
standardized list of phonetically balanced monosyllabic words in the absence of any
visual cues. This testing must be performed in quiet. The list may be recorded or
presented live, but in either case, the words should be presented at a level of amplification
that will measure your maximum ability to discriminate words, usually 35 to 40 dB
above your SRT. However, the amplification level used in the testing must be medically
appropriate, and you must be able to tolerate it. If you cannot be tested at 35 to
40 dB above your SRT, the person who performs the test should report your word recognition
testing score at your highest comfortable level of amplification.
g. Screening testing.
Physiologic testing, such as ABR and otoacoustic emissions (OAE), and pure tone testing
can be used as hearing screening tests. We will not use these tests to determine that
your hearing loss meets or medically equals a listing, or to assess functional limitations
due to your hearing loss, when they are used only as screening tests. We can consider
normal results from hearing screening tests to determine that your hearing loss is
not "severe'' when these test results are consistent with the other evidence in your
case record. See § 416.924(c).
3. What audiometric testing do we need when you have a cochlear implant?
a. If you have a cochlear implant, we will consider you to be disabled until age 5,
or for 1 year after initial implantation, whichever is later.
b. After that period, we need word recognition testing performed with any age-appropriate
version of the Hearing in Noise Test (HINT) or the Hearing in Noise Test for Children
(HINT-C) to determine whether your impairment meets 102.11B. This testing must be
conducted in quiet in a sound field. Your implant must be functioning properly and
adjusted to your normal settings. The sentences should be presented at 60 dB HL (Hearing
Level) and without any visual cues.
4. How do we evaluate your word recognition ability if you are not fluent in English?
If you are not fluent in English, you should have word recognition testing using an
appropriate word list for the language in which you are most fluent. The person conducting
the test should be fluent in the language used for the test. If there is no appropriate
word list or no person who is fluent in the language and qualified to perform the
test, it may not be possible to measure your word recognition ability. If your word
recognition ability cannot be measured, your hearing loss cannot meet 102.10B2 or
102.11B. Instead, we will consider the facts of your case to determine whether you
have difficulty understanding words in the language in which you are most fluent,
and if so, whether that degree of difficulty medically equals 102.10B2 or 102.11B.
For example, we will consider how you interact with family members, interpreters,
and other persons who speak the language in which you are most fluent.
5. What do we mean by a marked limitation in speech or language as used in 102.10B3?
a. We will consider you to have a marked limitation in speech if:
(i) Entire phrases or sentences in your conversation are intelligible to unfamiliar
listeners at least 50 percent (half) of the time but no more than 67 percent (two-thirds)
of the time on your first attempt; and
(ii) Your sound production or phonological patterns (the ways in which you combine
speech sounds) are atypical for your age.
b. We will consider you to have a marked limitation in language when your current
and valid test score on an appropriate comprehensive, standardized test of overall
language functioning is at least two standard deviations below the mean. In addition,
the evidence of your daily communication functioning must be consistent with your
test score. If you are not fluent in English, it may not be possible to test your
language performance. If we cannot test your language performance, your hearing loss
cannot meet 102.10B3. Instead, we will consider the facts of your case to determine
whether your hearing loss medically equals 102.10B3.