DI 24515.056 Evaluation Of Specific Issues — Mental Disorders —Determining Medical Equivalence
The program provision for finding medical equivalence to a listed impairment has a regulatory basis. Regulations 404.1525 and 416.925 point out that the Listing of Impairments describes impairments which are considered severe enough to prevent a person from doing any gainful activity. Regulations 404.1526 and 416.926 emphasize that for medical equivalence to be found, the medical findings of the impairment(s) must be at least equal in severity and duration to the criteria of a listed impairment, and that a decision of medical equivalence will be based only on medical evidence that is supported by medically acceptable clinical and laboratory diagnostic techniques. In deciding an issue of medical equivalence, the opinion of one or more medical or psychological consultants designated by the Commissioner is also to be considered.
The following guidelines describe the consideration to be given in determining medical equivalence in mental impairment claims and discuss the use of the Psychiatric Review Technique Form in making these determinations. There are also discussions of sources of evidence and responsibility for medical equivalence determinations in mental impairment claims.
B. Consideration of Mental Impairments Under the General Rules of Medical Equivalence
DI 24505.015 provides detailed guidelines for the determination of medical equivalence. Following are the three circumstances described in DI 24505.015B.2.b. and how they are applied to mental impairments:
1. Listed Impairment
A listed impairment for which one or more of the specified medical findings is missing from the evidence but for which other medical findings of equal or greater clinical significance and relating to the same impairment are present in the medical evidence.
To determine that such a mental impairment does not meet but equals a listed impairment, it must first be shown that the capsule definition of that impairment is satisfied. (The capsule definition follows the diagnostic category, e.g., Organic Mental Disorders, and describes the essential features of the impairment.) Then the program medical consultant (MC) or psychological consultant (PC) must show that the clinical findings, although different from the listed paragraph A criteria, are of equal clinical significance.
The impairment must also impose restrictions listed in paragraph B or C, if appropriate, of the listed impairment.
2. Unlisted Impairment
An unlisted impairment in which the set of criteria for the most closely analogous listed impairment is used for comparison with the findings of the unlisted impairment.
To determine an unlisted mental impairment is medically equivalent to a listed mental impairment, the unlisted mental impairment must fall within the parameters of the most closely analogous listed impairment. Then the findings of the unlisted mental disorder must be compared with the capsule definition and paragraph A and paragraph B (or C) criteria of the most closely analogous listing. An example of an unlisted impairment that may sometimes reach listing level severity is atypical depression. Atypical depression would be evaluated under Listing 12.04, Affective Disorders. If the atypical depression causes functional limitations such that at least two of the four paragraph B criteria are satisfied, Listing 12.04 would be equaled.
3. Combination of Impairments
A combination of impairments (none of which meet or equal a listed impairment), each manifested by a set of symptoms, signs, and laboratory findings which, combined, are determined to be equal in severity to that listed set to which the combined sets can be most closely related.
To determine that multiple impairments are medically equivalent to a listed impairment, it must first be determined that the individual impairments fall within the parameters of an appropriate listed impairment. The combined findings of the multiple impairments must then be compared with the most closely analogous listed impairment.
4. Additional Considerations
a. Duration of Impairment
In determinations of medical equivalence for listed, unlisted and combined impairments, there must also be a consideration of whether the mental impairment has lasted or is expected to last for a continuous period of at least 12 months.
b. Relationship of A and B Criteria
The medical criteria of paragraph A are used to substantiate the existence of a medically determinable mental impairment. The restrictions in the paragraph B criteria must be causally related to the medically determinable mental impairment in the paragraph A criteria. Finding of marked functional loss without a causal association with a medically determinable impairment cannot be used to establish equivalence.
c. Relationship to Mental Residual Functional Capacity Assessment
If the MRFC assessment indicates the individual's basic mental abilities and aptitudes have been substantially compromised, this may indicate the need to review the evidence (i.e., there is a “substantial loss” of ability to perform any one of the “basic” mental activities discussed in DI 25020.010) to determine if the impairment actually meets or equals a listed impairment. However, an MRFC assessment cannot serve as the basis for a finding of medical equivalent severity. Instructions for the purpose and completion of the MRFC assessment are in DI 24510.060.
C. Use of the Psychiatric Review Technique Form
Regulation 404.1520a and 416.920a state that a special procedure is to be followed in evaluating the severity of mental impairments. This procedure requires that pertinent signs, symptoms, functional limitations, and effects of treatment be recorded by the MC/PC on a standard document, which is the Psychiatric Review Technique Form (PRTF). The PRTF is an adjudicative tool that provides a technique for organizing findings of a mental disorder(s). It facilitates the MC/PC's analysis and decision that: (1) The reported mental disorder is not severe, or (2) that additional medical and/or other evidence is needed, or (3) that the findings of the reported mental disorder(s) meet or are medically equivalent to the requirements of a listed mental disorders category, or (4) that a mental residual functional capacity assessment is required. The PRTF does not substitute for an MC/PC's judgment. Rather, it serves to document that judgment and the specific information on which that judgment was based.
Section III of the PRTF contains subsections for each of the listed mental impairment categories with checkblocks to indicate whether the capsule definition for a listed category has been satisfied. Under each of these categories are criteria which are used to substantiate the existence of the impairment with checkblocks for indicating the presence or absence of each criterion, plus an “other” category for the MC/PC's substitution of criteria other than those cited in the subsection.
Section IV of the PRTF requires the MC/PC to rate functional limitations that are essential to work: (1) Activities of daily living, (2) social functioning, (3) concentration, persistence, or pace, and (4) deterioration or decompensation in work or work-like settings.
Inclusion of a finding in the “other” block in section II does not necessarily mean that the MC/PC believes the finding to be of diagnostic or prognostic importance equal to the listed findings. Rather, it means that there is a finding not found in the listing, that he/she believes should be considered in the overall evaluation of the case. For this and other reasons, checking of the “other” block, even when accompanied by appropriate functional manifestations covered in paragraph B or C, does not automatically require a finding of medical equivalence. As has been mentioned before, however, the finding of severe functional restriction requires careful review of the clinical data, because a listing may be met or equaled or it may be an indication that the functional data have not been correctly evaluated. (Instructions on the purpose and completion of the PRTF are in DI 24505.025.)
D. Determining Medical Equivalence in Particular Situations
1. Medical Equivalence And Mental Retardation
Listing 12.05, Mental Retardation applies primarily to adults with significantly subaverage intellectual functioning and deficits in adaptive behavior that were initially manifested in the individual's developmental period (before age 22). As with other mental impairment categories, the focus of Listing 12.05 is on the individual's inability to perform and sustain critical mental activities of work. Contrasted to other mental impairments that have A and B (or C) criteria, Listing 12.05 has four sets of criteria that are to be considered separately.
Listing 12.05A represents such a degree of mental deficiency that use of standardized measures of intellectual functioning are precluded. Individuals exhibiting the mental incapacity evidenced by the criteria in this listing are considered disabled.
Listing 12.05B introduces IQ scoring as a criterion and presents an impairment level in which inability to work is presumed on the basis of IQ scores alone.
Listing 12.05C is based on a combination of an IQ score with an additional and significant mental or physical impairment. The criteria for this paragraph are such that a medical equivalence determination would very rarely be required. However, slightly higher IQ's (e.g., 70-75) in the presence of other physical or mental disorders that impose additional and significant work-related limitation of function may support an equivalence determination. It should be noted that generally the higher the IQ, the less likely medical equivalence in combination with another physical or mental impairment(s) can be found.
This listing requires an IQ of 60 to 70 inclusive and a finding of at least two paragraph B functional limitations that are at a degree of limitation that satisfies the listing. Medical equivalence is possible in mental impairments with IQ's of 70 or above when the evaluation of either the test data or the functional manifestations warrant such a finding. For example, the MC may decide that the higher score is not a true reflection (e.g., practice effect) of the individual's intellectual endowment, or that the functional manifestations related to emotional deprivation or other causes may be greater than listing requirements (e.g., three paragraph B type manifestations may be at a level that satisfies the listing or that two paragraph B type manifestations are at a level that satisfies the listing, but one of them is at the “extreme” level.)
As was mentioned previously, there is a relatively close correlation between IQ test results and adaptive function when the cognitive deficit is the sole impairment. Thus, it would be very rare for people with IQ's above 75 and no other impairment to demonstrate functional limitations that satisfy the listing. If this occurs, there should be careful reevaluation of the data to determine if there is a coexisting mental disorder(s) that would explain the functional loss or, alternatively, whether the functional data has been correctly assessed.
2. Relationship of Adaptive Functioning or to IQ Scores
The term “adaptive functioning” refers to the individual's progress in acquiring mental, academic, social and personal skills as compared with other unimpaired individuals of his/her same age. Indicators of adaptive behavior include childhood developmental milestones (e.g., when did the individual first crawl, walk, tie shoes, feed/dress self, etc.), as well as educational and social achievements. The judgment of an MC/PC is necessary to affirm that adaptive functioning is consistent with IQ test results. If the individual's performance is significantly more deficient than would be reasonably expected for the tested IQ, the MC/PC should be alert to the possibility of a coexisting mental impairment(s), since the cognitive deficit alone may not explain the behavioral deficit. If a coexisting impairment does exist, a finding of medical equivalence may be possible on the basis of a combination of impairments. When no other medical explanation can be established for the deficiency in adaptive functioning, the MC/PC should carefully review all test results, clinical and psychological/psychiatric examination reports, and evidence of functional restrictions to make certain that all parameters of impairment severity have been properly assessed. Such marked functional restrictions can only be considered in the disability determination if they can be related to a medically determinable impairment.
E. Responsibility for Establishing Medical Equivalence
Findings of medical equivalence are the responsibility of a MC/PC designated by the Commissioner. The MC/PC's judgment is to be guided by a review of all of the evidence and reference to the most closely related listing.
2. Review By a Qualified Psychiatrist or Psychologist
The law requires that reasonable efforts be made to have a qualified psychiatrist or psychologist review of unfavorable decisions involving mental disorders. SSA has a goal of specialist review of all mental disorder determinations. In circumstances in which specialist review of all decisions is not possible because there is insufficient specialty staff, priority should be given to provide specialist review of unfavorable decisions, as required by law. To the extent that capacity for specialist review beyond unfavorable decisions exists, then allowance decisions involving complex or difficult issues should be included. Certainly, medical equivalence decisions are complex and should be included as a top priority.