BASIC (04-00)

DI 22510.025 CE Report Content Guidelines - Cardiovascular

A. Policy - General

Specific requirements exist in addition to all general internal medicine guidelines. See DI 22510.022.

B. Policy - Specific

1. General Examination

The report must:

  1. Provide a detailed description of the examination of the heart, including the heart sounds and rhythm and pulses.

  2. Describe:

    • Any jugular vein distention, including angle of reclining at which distention occurs;

    • Adventitious lung sounds;

    • Hepatomegaly;

    • Peripheral or pulmonary edema;

    • Cyanosis.

  3. Describe the impact of the chest discomfort, dyspnea or other cardiovascular symptoms on physical activities.

  4. Describe any drugs used (currently and in the recent past) for treatment of the cardiovascular disorder and indicate the dosage and the response to these drugs.

  5. Note participation in a cardiac rehabilitation program (e.g., progressive physical activity, educational or psychological support).

2. Congestive Heart Failure

The history must include a discussion of:

  1. The known factors in the development of the cardiac condition (e.g., myocardial infarction, rheumatic heart disease, hypertension, and congenital or other organic heart disease).

  2. Recurrent or persistent symptoms such as:

    • Fatigue;

    • Dyspnea;

    • Orthopnea;

    • Anginal discomfort.

3. Chest Discomfort And Other Symptoms

The report should describe:

  1. Chest discomfort of myocardial ischemic origin or other symptom(s) in the claimant's own words with respect to:

    • Presence;

    • Character;

    • Location;

    • Radiation;

    • Frequency;

    • Duration;

    • Usual inciting factors; and

    • Relief.

  2. The historical character of the chest discomfort to ascertain whether:

    • There is a predictable stable pattern of occurrence; and

    • There is evidence of a recent change in the pattern of symptoms.

  3. Whether therapy has been prescribed and how the claimant is responding to the therapy;

  4. Whether the discomfort occurs at rest or awakens the claimant from sleep and whether it is related to ingestion of food or movement of the upper extremities;

  5. The usual duration of the symptoms, especially chest discomfort, how symptoms are relieved, and the time required to obtain relief (e.g., rest or after taking specific drugs such as nitroglycerin).

4. Laboratory Tests

  1. Ancillary laboratory tests, (ECGs at rest and/or exercise) should be reported according to the Listing requirements.

  2. Chest x-rays or other appropriate imaging techniques should provide a basis for documenting cardiac enlargement for evaluation under Listing 4.02.

  3. Two-dimensional and Doppler echocardiograms, radionuclide (thallium 2 0 1 ) myocardial “perfusion” or radionuclide (technetium 99m) ventriculograms (RVG or MUGA) may provide a basis for assessing severe ventricular dysfunction or myocardial ischemia for evaluation under Listings 4.02 or 4.04.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510025
DI 22510.025 - CE Report Content Guidelines - Cardiovascular - 07/09/2012
Batch run: 07/09/2012
Rev:07/09/2012