BASIC (01-18)

DI 24508.010 Impairment or Combination of Impairments Equaling a Listing – Medical Equivalence

Citations:

20 CFR §§ 404.1525, 404.1526, and 404.1529, 416.925, 416.926, 416.929

SSR 17-2 Titles II and XVI: Evidence Needed by Adjudicators at the Hearings and Appeals Council Levels of the Administrative Review Process to Make Findings about Medical Equivalence

A. What is medically equals?

An impairment(s) is medically equal to a listed impairment in the Listing of Impairments (Listings) if it is at least equal in severity and duration to the criteria of any listed impairment.

B. How do we find medical equivalence?

IMPORTANT: When substituting a finding or symptom from a listing, you may substitute symptoms for other symptoms and findings for other findings only. Never substitute a symptom for a finding.

There are three ways to find medical equivalence. We consider whether the claimant has:

  • An impairment described in the Listings

  • An impairment not described in the Listings; or

  • A combination of impairments.

1. Considering an impairment(s) described in the Listings

We determine the claimant’s impairment is medically equivalent to a listing if either:

  • the impairment does not exhibit one or more of the findings specified in the particular listing—but, the claimant has other findings related to his or her impairment(s) that are at least of medically equal significance to the required criteria, or

  • the impairment does exhibit all of the findings specified in the particular listing, but one or more of the findings is not as severe as specified in the particular listing but, the claimant has other findings related to his or her impairment(s) that are at least of medically equal significance to the required criteria.

2. Considering an impairment(s) not described in the Listings

We determine the claimant’s impairment is medically equivalent to a closely analogous listing if:

  • the claimant has an impairment(s) not described in the Listings; and,

  • there is an analogous listing, and

  • the findings related to the claimant’s impairment are at least of equal medical significance to the analogous listing.

3. Considering a combination of impairments

We determine the claimant’s combination of impairment is medically equivalent to a closely analogous listing if the:

  • claimant has a combination of impairments, none of which meet a listing; and,

  • there is an analogous listing, and

  • findings related to the claimant’s impairments are at least of equal medical significance to those of the analogous listing.

C. What evidence do we consider when we determine whether an impairment(s) medically equals a listing?

When we determine if an impairment(s) medically equals a listing, we consider

  • all evidence in the record about the impairment(s), and

  • the impairment(s) effect(s).

D. Who is responsible for determining medical equivalence?

When the Disability Determination Services (DDS) or other designee of the Commissioner makes the initial or reconsideration disability determination, a DDS or other agency medical consultant (MC) or psychological consultant (PC) determines medical equivalence.

For cases in the disability hearing process or otherwise decided by a disability hearing officer (DHO), the DHO determines medical equivalence.

For cases at the administrative law judge (ALJ) or Appeals Council (AC) level, the ALJ or AC determines medical equivalence. The record must contain one of the following:

  • A prior administrative medical finding from an MC or PC from the initial or reconsideration adjudication levels supporting the medical equivalence finding, or

  • Medical expert (ME) evidence, which may include testimony or written responses to interrogatories, obtained at the hearings level supporting the medical equivalence finding, or

  • a report from the AC’s medical support staff supporting the medical equivalence finding.

E. Rationale content for each of the three ways to find medical equivalence?

1. General rationale requirements for any medically equal determination

a. Substituting a finding or symptom

When substituting an objective medical finding or symptom from a Listing, you may substitute symptoms for other symptoms only. Never substitute a symptom for an objective medical finding.

b. Medical equals and meets duration

If an impairment(s) medically equals a listing and meets the duration requirement, you must:

  • indicate which of the three ways you used to find medical equivalence, and

  • explain what findings you consider to be medically equivalent to the criteria in the listing you are equaling and why.

c. Adult cases

For all other medical equivalence determinations, document your explanation on:

  • a SSA-416-UF Medical Evaluation for equivalence based on physical impairments, or

  • a SSA-2506-BK Psychiatric Review Technique Form for equivalence based on mental impairments.

    IMPORTANT: When a combination of mental and physical impairments results in finding medical equivalence, use the PRT to document the mental portion of the explanation. We must use the PRT when evaluating mental impairments; see 20 CFR 404.1520a and 416.920a. Provide an explanation on the 416 for the physical impairment. For information on signature requirements on a combination of mental and physical impairments medical equivalence, see DI 24501.001B.4.

d. Child cases

For a Title XVI child, use the SSA-538 (Childhood Disability Evaluation) to document a medical equivalence determination.

2. Specific articulation requirements for each type of equivalence determination

a. Impairment described in the Listings

If a claimant has an impairment described in the Listings, there are two possible scenarios.

First scenario – The claimant’s impairment does not exhibit one or more of the findings specified in the listing:

  • Discuss the claimant’s impairment, medical findings, and non-medical findings.

  • Discuss the findings required to meet the listing.

  • Identify which required finding(s) is not present.

  • Discuss the finding(s) that is at least of equal medical significance to the required finding(s).

  • Explain why you can substitute that finding(s) to medically equal the listing.

  • Cite the listing for the medical equivalence determination.

Second scenario – The claimant’s impairment exhibits all of the required findings, but one or more of the findings is not as severe as specified in the listing:

  • Discuss the claimant’s impairment(s), medical findings, and non-medical findings.

  • Discuss the finding(s) required to meet the listing.

  • Identify the finding(s) related to the claimant’s impairment that is not as severe as specified in the listing.

  • Discuss the finding(s) that is at least of equal medical significance to the required findings.

  • Explain why you can substitute that finding(s) to medically equal the listing.

  • Cite the listing for the medical equivalence determination.

b. Impairment not described in the Listings

For an impairment not described in the Listings:

  • Discuss the claimant’s impairment(s), medical findings, and non-medical findings.

  • Identify the most closely analogous Listing.

  • Compare the finding(s) of the claimant’s impairment to the findings for the most closely analogous listing.

  • Explain why the finding(s) are at least of equal medical significance to the finding(s) of the most closely analogous listing.

  • Cite the most closely analogous listing used to determine medical equivalence.

c. Combination of impairments

For a combination of impairments:

  • Discuss the claimant’s impairments, medical findings, and non-medical findings.

  • Identify the listing you determine is most closely analogous.

  • Compare the findings of the claimant’s impairments to the findings for the most closely analogous listing.

  • Explain why the findings are at least of equal medical significance to the findings of the most closely analogous listing.

  • Cite the most closely analogous listing used to determine medical equivalence.

F. Examples of findings of medical equivalence significance to findings in a listing

The following are examples of cases listed in other sections of the Program Operations Manual (POMS) in which medical equivalence may be appropriate.

1. Musculoskeletal impairments

If clinical evidence shows the claimant has gross structural or functional joint abnormalities that are apparent on examination, you may consider equaling a listing without obtaining imaging evidence (e.g., x-ray or MRI) to corroborate the clinical examination. See DI 24515.020C.7.

2. Cochlear implants

If the claimant has cochlear implants and the Hearing in Noise Test (HINT) testing is not available despite efforts to find a consultative examiner to perform it, you may be able to use results from other tests in the claimant’s medical evidence of record to determine whether the impairment medically equals a listing. See DI 34001.012B How do we evaluate hearing loss?

3. Pulmonary disorders

If the pulmonary function tests (PFT) in the file do not adhere to our protocol, but indicate a possible listing level impairment, you may be able to substitute other clinical findings for the required PFT results. See DI 24515.020C.8.

4. Ischemic heart disease

Treating source evidence documenting the claimant’s chest discomfort symptoms, while on a regimen of prescribed treatment for ischemic heart disease, is sufficient evidence to establish ischemic heart disease without the claimant’s complete description of chest discomfort symptoms. Equaling a listing may be appropriate. See DI 24515.020C.3.

5. Congestive heart failure

When there are characteristics of both systolic and diastolic dysfunction, neither of which meets 4.02, but the impairment represents the same level of medical and functional severity as 4.02, then a medical equals decision may be appropriate.

If the claimant has objective evidence of chronic heart failure, and the only available imaging is a chest x-ray, which demonstrates cardiomegaly by an increased CT ratio greater than 0.5 during a period of stability, then a medical equals determination may be appropriate if the criteria in 4.02B are also met. See DI 34001.016 Cardiovascular System.

6. Chronic venous insufficiency

Listing 4.11 requires extensive brawny edema involving at least two-thirds of the leg between the ankle and knee or the distal one-third of the lower extremity between the ankle and hip. , If the claimant has brawny edema involving both lower extremities and extending from the toes (rather than the ankles) to the mid-tibia, a medical equals may be appropriate.

See also DI 34001.016 Cardiovascular System.

7. Chronic liver disease

A diagnosis of chronic liver disease with spontaneous bacterial peritonitis with an ascetic peritoneal fluid white blood cell (WBC) count of at least 1000 WBC per cubic millimeter may equal listing 5.05C providing that other causes of peritonitis (such as tuberculosis, malignancy, and perforated bowel) are excluded.

See also DI 34001.018 Digestive System.

8. Chronic renal disease

A treating physician's description of chronic renal disease and evidence of ongoing dialysis may be sufficient evidence to establish end stage renal disease equaling listing 6.03. See DI 24515.020C.4.

9. Intellectual disorder

If a child IQ testing is not “current” as explained in DI 24515.055D.1, you may equal listing 112.05 with outdated IQ scores – up to six months after the relevant 1, 2, or 4 year periods; and, the other case evidence confirms the child’s functioning is consistent with the IQ score. See DI 24515.020C.5.

10. Cancer

A hospital discharge summary (or the report from a treating physician), describing listing level carcinoma, sufficient evidence to establish disability without corroborating pathology and operative reports. Equaling a listing may be appropriate. See DI 24515.020C.2.

G. Examples of an unlisted impairment determinations

1. Blepharospasm

Blepharospasm generally responds to therapy. If therapy is not effective, we will consider how the involuntary closure of the eyelids affects the person’s ability to maintain visual functioning over time (that is, on a sustained basis).  Consider whether the person’s impairment medically equals listing 2.04A, 2.04B, 102.04A, or 102.04B. See details: DI 34001.012 Special Senses and Speech.

2. Enteral feeding

For a child younger than age 3, a requirement for supplemental daily enteral feeding via a nasojejunal (NJ) tube may be equivalent to the requirement for supplemental daily enteral feeding via a gastrostomy in 105.10.

See DI 34005.105H How do we evaluate the need for supplemental daily enteral feeding via a gastrostomy?

H. Compassionate allowance (CAL) conditions

Many CAL conditions may medically equal a listing.

Equals Table

CAL Conditions

Consider Equaling Listing(s):

Allan-Herndon-Dudley Syndrome

111.07 B

See DI 23022.925.

Aplastic Anemia

7.17 or 107.17

See DI 23022.929.

Multiple System Atrophy

11.04 or 12.02

See DI 23022.630.

Breast Cancer

13.10 A

See DI 23022.125.

Canavan Disease

110.08 B

See DI 23022.130.

Cardiac Amyloidosis—AL Type

4.02 or 4.05

See DI 23022.580.

Congenital Lymphedema

101.08

See DI 23022.939.

Mixed Dementia

12.02, 11.04, 11.06, or 11.17

See DI 23022.455.

Esthesioneuroblastoma

13.13 B1

See DI 23022.156.

Farber’s Disease

114.09 A, 114.09 B, or 114.09 D

See DI 23022.160.

Giant Axonal Neuropathy

111.02 or 112.02

See DI 23022.181.

Hemophagocytic Lymphohistiocytosis

114.07 A, 114.07 B, or 114.07 C

See DI 23022.405.

Hypocomplementemic Urticarial Vasculitis Syndrome

3.02 A

See DI 23022.765.

Idiopathic Pulmonary Fibrosis

3.02 A, 3.02 B, 3.02 C, or 3.09

See DI 23022.420.

Joubert Syndrome

112.02

See DI 23022.202.

Kufs Disease—Type B

11.04 or 11.06

See DI 23022.790.

Leptomeningeal Carcinomatosis

13.13 A

See DI 23022.216.

Lewy Body Dementia

11.04 or 11.06

See DI 23022.610.

Lymphomatoid Granulomatosis – Grade III

13.13 A1 or 113.13

See DI 23022.800.

Malignant Brain Stem Gliomas—Childhood

13.13 A2

See DI 23022.805.

Malignant Ectomesenchymoma

13.13 A2

See DI 23022.226.

Malignant Gastrointestinal Stromal Tumor

13.16 B2

See DI 23022.963.

Marshall-Smith Syndrome

2.09

See DI 23022.231.

Merkel Cell Carcinoma—with metastasis

13.03 A

See DI 23022.825.

Myoclonic Epilepsy with Ragged Red Fibers Syndrome

11.17 or 12.02

See DI 23022.830.

Nephrogenic Systemic Fibrosis

1.02 A, 1.02 B, 6.02 C, or 14.04 B

See DI 23022.835.

Neurodegeneration with Brain Iron Accumulation—Type 1 and 2

11.06

See DI 23022.836.

Ovarian Cancer

13.23 E1a

See DI 23022.260.

Pearson Syndrome

107.03

See DI 23022.855.

Pelizaeus-Merzbacher Disease—Classic Form

11.06

See DI 23022.860.

Peritoneal Mesothelioma

13.16

See DI 23022.270.

Peritoneal Mucinous Carcinomatosis

13.15 B or 13.23 E1

See DI 23022.975.

Primary Progressive Aphasia

11.04 A

See DI 23022.485.

Progressive Supranuclear Palsy

11.06

See DI 23022.650.

Revesz Syndrome

7.17, 107.03 or 110.08 B

See DI 23022.286.

Salivary Cancers

13.14 B

See DI 23022.290.

Sanfilippo Syndrome

110.08 B

See DI 23022.495.

Small Cell Cancer of the Thymus

13.14 B

See DI 23022.290.

Stiff Person Syndrome

11.06

See DI 23022.905.

Spinal Muscular Atrophy (SMA) - Types 0 and 1

111.22

See DI 23022.330.

Tabes Dorsalis

11.08 or 11.17

See DI 23022.910.

Ventricular Assist Device Recipient—Left, Right, or Biventricular

4.09 or 104.09

See DI 23022.570.

X-Linked Myotubular Myopathy

3.02 B, 3.04 B, 3.07 or 5.07 A

See DI 23022.347.

I. References

DI 22001.001 Sequential Evaluation of Title II and Title XVI Adult Disability Claims

DI 24501.020 Establishing a Medically Determinable Impairment (MDI)

DI 24501.021 Evaluating Symptoms

DI 24515.056 Evaluation of Specific Issues—Mental Disorders—Determining Medical Equivalence

DI 25220.010 Meets or Medical Equals

DI 34001.000 Listing of Impairments – Current Part A Listings – Table of Contents

DI 34005.000 Listing of Impairments – Current Part B Listings – Table of Contents


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DI 24508.010 - Impairment or Combination of Impairments Equaling a Listing - Medical Equivalence - 03/19/2018
Batch run: 03/19/2018
Rev:03/19/2018