TN 48 (11-94)
DI 32594.015 Determining Disability For Cardiovascular Impairments
This is a new POMS instruction to implement the State of New York decision in New York. In determining disability, all evidence is considered at each step of the sequential evaluation process (regulations 404.1520 and 416.920). Adjudicators may not determine that a claim is denied (or ceased) based exclusively on the results of an exercise test (ET). Adjudicators must also give appropriate weight to treating source opinion, as well as other signs, symptoms, and laboratory findings, in determining whether any cardiac impairment is disabling.
1. Determinations at Step 2
Do not deny at step 2 of the sequential evaluation process exclusively on the results of an ET, even where the ET suggests the capacity for heavy work. All medical evidence must be considered, including all signs, symptoms, laboratory findings, and treating source opinion evidence. The combined effects of multiple impairments must also be considered. Additionally, do not deny at step 2 when the claimant has any of the following cardiac impairments:
status post coronary artery bypass grafting;
status post coronary angioplasty;
heart valve replacement;
organic heart disease with documented heart failure of less than listed severity (see Listing 4.02).
2. Determinations at Step 3 (meets or equals the listing) of sequential evaluation process
In evaluating heart disease at step 3, the criteria in Listings 4.02 (congestive heart failure), 4.03 (hypertensive vascular disease), 4.04 (ischemic heart disease), 4.05 (recurrent arrhythmias),4.09 (myocardiopathies, rheumatic or syphilitic), and 4.11 (aneurysm of the aorta or major branches) apply.
Consider all medical evidence (DI 32594.015B.) to determine if findings meet or equal a listing. If a listing is not met, an equals assessment must be made.
You must not presume that ET results, or any other test results, are entitled to primary or extra weight in determining disability in the “equals” analysis. You may find an impairment of cardiac origin equal to Listing 4.04, even where the file contains “documentation of an acceptable treadmill exercise test” (TET), as defined in 4.00G of the Listings, that does not meet the criteria in Listing 4.04A. Depending upon the actual case record in a given case, and the reliability, comprehensiveness and source of the evidence, it may sometimes be appropriate to give more weight to certain findings as opposed to other findings. For equals determinations, all evidence must be considered.
The following list provides a number of examples of findings that can be substituted for a missing finding(s) in equals determinations:
chest pain, discomfort, or tightness not precisely as described in 4.00E, but which is likely to be of cardiac origin (e.g., chest discomfort or tightness occurring with exposure to environmental stressors, such as extremes of temperature, humidity, or fumes, or occurring with exposure to psychological stress, or occurring during performance of an ET);
other symptoms (e.g., fatigue, dyspnea) when considered to be of cardiac origin;
results of ETs other than TET (e.g., bicycle or arm ergometer),
results of arteriograms, echocardiograms, radionuclide ventriculography (e.g., MUGA), or other studies of record (DI 32594.020) whose findings demonstrate a level of severity upon which a presumption of inability to work can be made.
The listings are designed to screen in (i.e., allow) individuals who are so severely disabled that they cannot do any gainful activity. The following list provides a number of examples that can be used to screen in (i.e., allow) as equal to the ischemic heart disease or congestive heart failure listings individuals with listing-level impairments (i.e., individuals who are symptomatic on ordinary physical activity).
Cyanosis at rest documented by PO of 65 Torr or less at sea level.
Pulmonary hypertension secondary to heart disease with a mean pulmonary arterial pressure elevated to 70 percent or more of the mean systemic arterial pressure.
Cyanosis at a workload equivalent to 5 METs or less with PO of 65 Torr or less at sea level.
Failure to increase systolic pressure by 10mmHg compared to resting pressure, or decrease in systolic pressure below usual clinical resting level at a workload equivalent to 5 METs or less.
Positive thallium 201 perfusion study indicative of ischemia at an exercise level equivalent to 5 METs or less.
Markedly symptomatic exercise intolerance at a workload equivalent to 5 METs or less with signs attributable to inadequate cerebral perfusion, such as ataxic gait or mental confusion.
Symptoms of ischemia or heart failure, and findings on arteriograms, echocardiograms, MUGA, or other studies of record (DI 32594.020) demonstrating a threshold level of coronary stenosis or ventricular dysfunction indicative of listing-level impairment (even where there is a TET in file that does not meet the criteria in Listing 4.04A).
3. Determinations at Steps 4 and 5 of the sequential evaluation process
All evidence of record is considered (see DI 32594.015B.1 and 2) in determining residual functional capacity (RFC).
NOTE: The TET provides an estimate of aerobic capacity for walking on a grade in an environmentally controlled laboratory. Therefore, TET results do not correlate with the ability to perform several other types of exertional activities and do not provide an estimate of the ability to perform throughout a workday activities required for gainful work in all possible work environments. A TET (or other ECG modality) is not to be relied on as the sole basis for rejecting a claim. You must consider other signs, symptoms, laboratory findings, treating source opinions, environmental restrictions, susceptibility to psychological stress, or other evidence that may establish the claimant's disability. See DI 32594.020A.5.c. for a complete discussion of evaluating test results.
Take the following into consideration:
1. Medical evidence
Consider all the medical evidence (regulations 404.1508 and 416.908) including, but not limited to:
Clinical history of impairment:
symptoms, including frequency and character of pain, dyspnea, fatigue, palpitations, syncope;
clinical course since onset of illness;
treatment and results of treatment;
impact of the impairment on activities of daily living (e.g., self-care, household, occupation, recreational, and social);
ability to perform work-related activity.
Physical examination findings (signs).
Results of laboratory tests available in evidence of record:
resting electrocardiogram (ECG),
TET or other ETs (e.g., bicycle or arm ergometer), including the development of chest pain, fatigue, blood pressure changes, arrhythmias, and other signs of ischemia that occur during the test. Consider all signs, symptoms, and laboratory findings demonstrated during exercise testing, irrespective of whether the test is completed;
radionuclide studies (MUGA, thallium);
ambulatory ECG monitoring.
Treating physicians' opinions about a person's condition:
clinical findings and diagnostic impression;
what person can still do despite impairment;
prognosis for improvement;
presence of other relevant factors (see DI 32594.015B.2).
2. Other relevant factors
Capacity for pushing, pulling, or lifting above the shoulders.
Effect of work-related environmental stressors (e.g., extremes of temperature, humidity, fumes, noise, hazardous machinery).
Any adverse effects of prescribed medication, activity, or therapy.
3. Determination rationale
Where disability is found to exist or to continue, i.e., where a fully favorable decision is warranted, no decision rationale is needed.
Where disability is denied or ceased, state clearly the reasons for the determination including, but not limited to:
what specific evidence was considered;
what weight was given to findings (e.g., exercise test results) which were considered;
what weight was given to observations and opinions from the treating sources;
which cardiovascular listings were evaluated and were found not met or equaled;
what and how other relevant factors were considered (see DI 32594.015B.2.), including what weight was given to the claimant's subjective complaints (e.g., pain, fatigue), or other complaints of functional restrictions.
Where the determination is partly unfavorable, explain the basis for establishing a period of disability different than that alleged by the claimant.