Except as otherwise noted in Listing 12.04, the provisions in this section were in effect from August 1968 through March 26, 1979.
Functional loss may be due to an anatomical loss or to a loss of use of a part due to deformity, adhesions, defective innervation, or other pathology. Pain may be an important factor in causing functional loss, but it must be associated with relevant abnormal findings. Evaluations of musculoskeletal impairments should be supported where applicable by detailed descriptions of ranges of motion, status of the musculature and any sensory, reflex or circulatory deficits and pertinent X-ray findings.
Major joints as used herein refer to hip, knee, ankle, shoulder, elbow or wrist and hand. (Wrist and hand considered together as one major joint.)
The measurements of restricted motion and ankylosis are based on the technic of measurements described in Guides to the Evaluation of Permanent Impairment Extremities and Back by the Committee on Rating of Mental and Physical Impairment, Special Edition, JAMA, February 15, 1958.
CATEGORY OF IMPAIRMENTS, MUSCULOSKELETAL
History of jont pain and swelling in two or more major joints and morning stiffness persistent on activity; AND
Signs of joint enlargement, or effusion, and motion limitation with periarticular muscle wasting in two or more major joints; AND
X-ray evidence of abnormality of a major joint (i.e., osteoporosis or decalcification or narrowing of joint space) AND one of the following:
anatomical deformity in one major joint, such as joint subluxation, contracture, bony or fibrous ankylosis, joint instability, ulnar deviation, or hyperextension, with resultant limitation of motion; OR
positive serologic test for rheumatoid factor; OR
elevated sedimentation rate (Wintrobe) greater than 20 mm. per hour in females or 10 mm. per hour in males; OR
positive C-reactive protein; OR
polymorphonuclear leukocytosis in synovial fluid aspirate; OR
characteristic histologic changes in biopsy of synovial membrane or subcutaneous nodule.
NEUROGENIC ARTHROPATHY (e.g., Charcot) affecting at least one major weight bearing joint or one major joint in each of the upper extremities.--WITH:
Instability or subluxation; AND
Associated loss of sensory modalities in appropriate distribution.
HYPERTROPHIC (osteo or degenerative),
GOUTY, INFECTIOUS OR TRAUMATIC ARTHRITIS.--WITH:
History of pain and stiffness in the involved joints; AND
X-ray evidence of joint space narrowing with osteophytosis (exostosis) or bony destruction with erosions and cysts, or subluxation, or ankylosis of involved joints AND one of the following:
abduction of both arms at shoulders restricted to less than 90 degree; OR
ankylosis (fibrous or bony consolidation or fixation) of hip at less than 20 degrees or more than 30 degrees of flexion, measured from neutral position; OR
ankylosis or fixation of knee at more than 10 degrees from neutral position; OR
limitation of flexion of both hips to 50 degrees or less from neutral position (including ankylosis of both hips at any angle); OR
limitation of flexion of both knees to 30 degrees or less from the neutral position (including ankylosis of both knees at any angle); OR
combined involvement of single hip and knee in contralateral extremity, with impairment in each as in 4. or 5. above; OR
reconstructive surgery or surgical arthrodesis of a major weight-bearing joint (hip, knee, ankle, or tarsal region) and return to full weight-bearing status did not occur, or is not expected to occur within 12 months of onset of disability; OR
X-ray evidence of lumbar spine abnormalities as in B. above with motion of dorsolumbar spine limited to 5 degrees or less from neutral position and impairment of single hip or knee as in 4. or 5. above.
DISORDERS OF SPINE.--WITH:
Fracture of vertebra, residuals of--With cord involvement with appropriate sensory and motor loss; OR
Generalized osteoporosis with pain, limitation of back motion, paravertebral muscle spasm, and compression fracture of a vertebra; OR
Ankylosis or fixation of cervical or dorsolumbar spine at 30 degrees or more of flexion measured from the neutral position AND one of the following:
calcification of the anterior and lateral ligaments as shown by X-ray; OR
bilateral ankylosis of sacroiliac joints and abnormal apophyseal articulations as shown by X-ray.
TUBERCULOSIS OF THE SPINE OR ANY
MAJOR JOINT.-- Active.
NERVE ROOT COMPRESSION SYNDROME (due to any cause).--WITH:
Pain and motion limitation in back or neck; AND
Cervical or lumbar nerve root compression as evidenced by appropriate radicular distribution of sensory, motor, and reflex abnormalities.
OSTEOMYELITIS (demonstrated by X-ray):
Pelvis, vertebra, femur, tibia or a major joint of an upper or lower extremity, with persistent activity or occurrence of at least 2 episodes in the 6 months since onset of disability manifested by local or systemic signs or laboratory findings, (e.g., heat, redness, swelling, drainage, leucocytosis, or increased sedimentation rate); OR
With multiple localizations and systemic manifestations such as anemia (hematocrit of 30 percent or less) or amyloid changes.
AMPUTATION OF; OR ANATOMICAL DEFORMITY OF (i.e., loss of major function due to degenerative changes associated with vascular or neurological deficits, traumatic loss of muscle mass or tendons and X-ray evidence of bony or fibrous ankylosis at an unfavorable angle, joint subluxation or instability):
Both hands; OR
Both feet; OR
One hand and one foot.
AMPUTATION OF LOWER EXTREMITY (at or above the tarsal region)--
Hemipelvectomy or hip disarticulation; OR
Evaluate an amputation associated with peripheral vascular disease or diabetes mellitus under the criteria in §4.13 or §9.08; OR
Inability to use prosthesis effectively, without other assistive devices, due to:
vascular disease; OR
neurological complications (e.g., loss of position sense); OR
stump complications persisting, or expected to persist, for at least 12 months from onset of disability, OR
disorder of contralateral lower extremity causing mobility restriction.
FRACTURE OF FEMUR, TIBIA, TARSAL BONE OR PELVIS.--WITH: solid union not evident on X-ray AND return to full weight-bearing status did not occur, or is not expected to occur, within 12 months of onset.
FRACTURES AND/OR SOFT TISSUE INJURIES OF AN UPPER EXTREMITY.--
With non-union of a fracture of the shaft of the humerus, radius, or ulna under continuing surgical management directed toward restoration of functional use of the extremity and such function was not restored or expected to be restored within 12 months after onset; OR
Requiring a series of staged surgical procedures within 12 months after onset for salvage and/or restoration of major function of the extremity, and such major function was not restored or expected to be restored within 12 months after onset; OR
After maximum benefit from surgical therapy has been achieved (i.e., there have been no significant changes in physical findings and/or X-ray findings for any 6-month period after the last definitive surgical procedure), the residual of fractures and/or soft tissue injuries of an upper extremity should be evaluated under the criteria in §1.09 when associated with residual impairment of another extremity.
SPECIAL SENSE ORGANS
Causes of Disability .--Disease or injury of the special sense organs may produce disability by reduction of the ability to see or hear. Loss of central vision results in inability to distinguish detail and prevents reading and fine work. Loss of peripheral vision restricts the ability of an individual to move about freely. Loss of hearing impairs ability to communicate with others by misinterpretation of ideas and orders and results in lack of awareness to danger. The extent of impairment of sight or hearing should be determined by visual or auditory testing.
Central Visual Acuity .--A loss of central visual acuity may be caused by impaired distant and/or near vision. However, for an individual to meet the level of severity described in §2.02 and 2.04 only the remaining central visual acuity for distance of the better eye with best correction using the Snellen test chart may be used. Correction obtained by special visual aids (e.g., contact lenses) will be considered only if the individual has the ability to wear such aids.
Field of Vision. --Disability due to loss of peripheral vision may result if there is contraction of the visual fields. The contraction may be either symmetrical or irregular. For the phakic eye (the eye with a lens), the extent of the remaining visual field will be determined by usual perimetric methods, utilizing a 3 mm. white disc target at a distance of 330 mm. under illumination of not less than 7 foot candles. For the aphakic eye (the eye without a lens), the visual field must be determined by utilizing a 6 mm. white disc at a distance of 330 mm. without corrective lenses.
Field measurements must be accompanied by notated field charts, a description of the type and size of the target and the test distance. If corrective lenses have been used, this fact must be stated.
Muscle Function .--Paralysis of the third cranial nerve producing ptosis, paralysis of accommodation, and dilation and immobility of the pupil may cause significant visual impairment. When all the muscles of the eye are paralyzed, including the iris and ciliary body (total ophthalmoplegia), the condition is disability provided it is bilateral. A finding of disability based primarily on impaired muscle function must be supported by a report of an actual measurement of ocular motility.
Visual Efficiency .--Loss of visula efficiency may be caused by disease or injury resulting in a reduction of central visual acuity and/ or visual field. The visual efficiency of one eye is the product of the percentage of central visual efficiency and the percentage of visual field efficiency. (See Tables No. 1 and 2, §2.09).
Special Situations. --Aphakia represents a visual handicap in addition to the loss of central visual acuity. The term monocular aphakia would apply to an individual who has had the lens removed from one eye, and who still retains the lens in his other eye or to an individual who has only one eye which is aphakic. The term binocular aphakia would apply to an individual who has had both lenses removed. In cases of binocular aphakia, the central visual efficiency of the better eye will be accepted as 75 percent of its value. In cases of monocular aphakia, where the better eye is aphakic, the central visual efficiency will be accepted as 50 percent of its value. (If an individual has binocular aphakia, and the central visual acuity in the poorer eye can be corrected only to 20/200, or less, the central visual efficiency of the better eye will be accepted as 50 percent of its value).
Ocular symptoms of systemic disease may or may not produce a disabling visual impairment. These manifestations should be evaluated as part of the underlying disease entity by reference to the particular body system involved.
Deafness should be evaluated in terms of the person's ability to hear and distinguish speech. The degree of functional hearing loss is that loss of hearing and discrimination for speech which is not restorable by a hearing aid. Loss of hearing may be determined with an audiometer or by other appropriate auditory testing. Discrimination for speech may be determined with a speech audiometer or a hearing aid and the use of phonetically balanced word lists (e.g., the PB-50's prepared at Harvard University or the W-22 recordings developed by the Central Institute for the Deaf). These special test lists consist of words selected so that the frequency of speech sounds in the group is the same as the frequency of the same sounds in an average vocabulary of conventional American English.
CATEGORY OF IMPAIRMENTS, SPECIAL SENSE ORGANS
IMPAIRMENT OF CENTRAL VISUAL ACUITY.-- Remaining vision in the better eye after best correction is 20/200 or less.
CONTRACTION OF VISUAL FIELDS.--
To 10 degrees or less from the point of fixation; OR
So the widest diameter subtends an angle no greater than 20 degrees; OR
To 20 percent or less visual field efficiency.
LOSS OF VISUAL EFFICIENCY.-- Visual efficiency of better eye after best correction 20 percent or less. (The percent of remaining visual efficiency equals the product of the percent of remaining central visual efficiency and the percent of remaining visual field efficiency.)
COMPLETE HOMONYMOUS HEMIANOPSIA
TOTAL BILATERAL OPHTHALMOPLEGIA
MENIERE'S SYNDROME--. Severe; with frequent and typical attacks, vertigo, deafness and cerebellar gait.
HEARING IMPAIRMENTS (not correctible by a hearing aid)--manifested by:
Absence of air and bone conduction in both ears (auditory perception of not more than one pure tone at high volume will be considered as absence of air and bone conduction); OR
No more than 40 percent discrimination for speech (ability to hear and understand no more than 40 out of 100 words of special test lists of words using a speech audiometer or hearing aid).
PNEUMOCONIOSIS (demonstrated by X-ray evidence)--WITH:
Nodular or focal fibrosis (non-conglomerative). Evaluate under the criteria for chronic obstructive airway disease in §3.02; OR
Interstitial or disseminated fibrosis or conglomerative disease. Evaluate under the criteria for pulmonary fibrosis in §3.04; OR
Where A and B are mixed or cannot be differentiated--evaluate under the criteria in §3.02 or §3.04.
BRONCHIECTASIS (demonstrated by radio-opaque material)--WITH:
Episodes of acute bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum) occurring at least once every two months; OR
Impairment of pulmonary function due to extensive disease should be evaluated under the criteria for chronic obstructive airway disease in §3.02 or where extensive fibrosis is evident on chest film, under the criteria for pulmonary fibrosis in §3.04.
PULMONARY TUBERCULOSIS (caused by M. tuberculosis or pathogenic atypical mycobacteria)--WITH:
Positive culture (or positive guinea pig inoculation) of specimen obtained more than 3 months following onset of disability; OR
Serial X-ray evidence of increasing extent of lesion more than 3 months following onset of disability; OR
Far-advanced disease with cavitation and positive culture (or positive guinea pig inoculation) of specimen obtained at any time following onset of disability; OR
Impairment of pulmonary function due to extensive disease should be evaluated under the criteria in §3.02, §3.04 or §3.05.
MYCOTIC INFECTION OF LUNG.--WITH:
Culture of specific organisms from sputa and serial X-ray evidence of increasing or decreasing extent of lesion, both occurring more than 3 months following onset of disability; OR
Culture of specific organisms from sputa at any time following onset of disability and current X-ray evidence of a lesion and episodes of hemoptysis occurring at least once every two months; OR
Impairment of pulmonary function due to extensive disease should be evaluated under the criteria in §3.02, §3.04, or §3.05.
ORGANIC LOSS OF SPEECH.--WITH:
Laryngectomy or stenosis of the larynx or paralytic aphonia provided there is inability to produce, by the use of some other anatomical part, speech which can be heard, understood, and sustained; OR
Central nervous system lesion resulting in severe sensory or motor aphasia paralleling the speech impairment under A. above.
Congestive heart failure. Evaluate under the criteria in §4.02; OR
Right-sided congestive failure as evidenced by peripheral edema and liver enlargement and right ventricular enlargement or outflow tract prominence on X-ray or fluoroscopy.
BRONCHOPLEURAL FISTULA (persistent) with empyema.
Regardless of the cause of heart disease, disability results from one of two principal consequences of the disease. One is congestive heart failure and the other is ischemia or death of heart muscle. In diseases of the arteries and veins, disability may result from impairment of the vasculature in the central nervous system, eyes, kidneys and extremities. The criteria for evaluating both heart and vascular disorders are expressed in terms of symptoms, signs, and laboratory findings.
Congestive heart failure is considered in the listings under one category regardless of the etiology producing the heart failure (e.g., arteriosclerotic, hypertensive, rheumatic, pulmonary, congenital, or syphilitic heart disease). Congestive heart failure is not considered to be established for the purpose of §4.02 unless there is evidence at some point in time of signs of vascular congestion such as hepatomegaly, peripheral or pulmonary edema as well as other appropriate findings.
Hypertensive vascular disease produces disability when it causes complications in one or more of the four main end organs; i.e., the heart, the brain, the kidneys, and the eyes (retinas). This may occur singly or in combination and to varying degrees in the different end organs.
Angina Pectoris. --The complaint of chest pain, which is considered to be of cardiac origin, must be associated with abnormal laboratory findings. Thus chest pain, by itself, in the absence of corroborative evidence is insufficient to warrant a finding of disability. Angina pectoris, as used herein, is considered to be substernal pain precipitated by effort and relieved by rest or nitroglycerin, described as crushing, squeezing, burning, pressing, or an equivalent thereof. Excluded are sharp, sticking, or rhythmic pains.
Electrocardiographic evidence is best presented in the form of the actual tracings. Where an electrocardiogram (ECG) is obtained at the expense of the Administration, the tracing must be incorporated in the file. In those cases where an ECG has not been obtained at the expense of the Administration, an interpretation alone is not sufficient and a detailed description of the CDG abnormalities must be given.
When a resting ECG is normal and an ECG exercise test is indicated, it should be performed according to a technique such as the one described in Master, A.M., and Rosenfeld, I.: “Excercise Electrocardiography as an Estimate of Cardiac Function” , Diseases of the Chest , 51:347, 1967. The criteria in §4.07 are based upon the Master and Rosenfeld technique and only negative results obtained by the Master and Rosenfeld technique will be used to determine that the criteria in § 4.07 are not met. Negative results from techniques other than the Master and Rosenfeld technique are not determinative. However, when some other standardized ECG exercise test has ben performed, adequately described abnormal test results will be considered equivalent to meeting the criteria described in §4.07. Where the ECG exercise test is obtained at the expense of the Administration, the tracings must be made a part of the file and must be adequately marked as to the lead and duration of time elapsed from performance of the exercise. The report should contain the number of trips indicated, the number of trips actually completed, and the time spent doing the exercise. If the exercise test could not be completed in the required period of time, the circumstances should be described.
Surgical Procedures in Heart Disorders. --The amount of function restored and the time required to effect improvement in an individual treated by heart surgery varies considerably with the nature and extent of the disorder prior to surgery, the type of surgery involved and many other individual factors. If the criteria described for heart disease are met, proposed heart surgery will not militate against a finding of disability. If insufficient time has elapsed to assess whether impairment of requisite severity persists after surgery, severity of the impairment will be determined by preoperative findings.
CATEGORY OF IMPAIRMENTS,
CONGESTIVE HEART FAILURE (See §4.00B)--WITH:
Cardio-thoracic ratio of 55% or greater, or equivalent enlargement of the transverse diameter of the heart, as shown on teleroentgenogram (6 foot film); OR
Extension of the cardiac shadow (left ventricle) to the vertebral column on lateral chest roentgenogram and total of S in V1 or V2 and R in V5 or V6 of 35 mm. or more on ECG; OR
ECG showing QRS duration less than 0.12 second and R of 5 mm. or more in V1 and R/S of 1.0 or more in V1 and transition zone (decreasing R/S) left of V1 with one of the following:
enlargement of the left atrium as evidenced by a double shadow on a PA chest roentgenogram; OR
distortion of the barium filled esophagus.
HYPERTENSIVE VASCULAR DISEASE (apply this section if diastolic pressures are consistently in excess of 100 mm. Hg.)--WITH:
Hypertensive retinopathy evidenced by hemorrhages, or cotton wool patches, with reduction in the caliber of the arterioles and arteriovenous crossing defects (or papilledema); OR
Impaired renal function as described under the criteria in §6.02; OR
Cerebrovascular damage as described under the criteria in §11.04; OR
Congestive heart failure as described under the criteria in § 4.02; OR
Angina pectoris as described under the criteria in §4.06, §4.07, or §4.08.
MYOCARDIAL INFARCTION associated with consistent ECG abnormalities (or consistent abnormalities of serum enzymes)--AND one of the following:
Chest discomfort on effort, relieved by rest or nitroglycerin; OR
Another documented myocardial infarction within 6 months following the previous infarction.
PERSISTENT HEART BLOCK OR RECURRENT ARRHYTHMIA, as evidenced by ECG (in absence of digitalis) with cardiac syncope.
ANGINA PECTORIS, (as defined in §4.00D) associated with resting ECG abnormalities, in the absence of digitalis (in the presence of digitalis, the pre-digitalis ECG should be evaluated) showing ONE of the following:
Depression of the ST segment to more than 0.5 mm. in any of leads I, II, aVL, aVF, V1 to V6 ; OR
Elevation of ST segment to 2 mm. or more in any of leads I, II, III, V 4 , V5 , or V6 ; OR
Inversion of T-wave to 5.0 mm. or more in any 2 leads except leads III, aVR, V1 and V2 ; OR
Inversion of T-wave to 1.0 mm. or more in any of leads I, II, aVL, V2 to V6 AND R-wave of 5.0 mm. or more in lead aVL and R-wave greater than S-wave in lead aVF; OR
Second or third degree heart block; OR
Left bundle branch block as evidenced by QRS duration of 0.12 second or more in leads I, II, or III and R peak duration 0.06 second or more (in absence of myocardial infarction) in leads I, aVL, V5 , or V6 .
ANGINA PECTORIS (as defined in §4.00D) associated with standardized ECG exercise test abnormalities (see §4.00E) in the absence of digitalis (in the presence of digitalis, the pre-digitalis ECG should be evaluated), showing ONE of the following:
Development of depression of ST segment to more than 0.5 mm. which lasts for at least 0.12 second and appears in at least 2 consecutive complexes in any lead; OR
Development of bundle branch block.
CHEST DISCOMFORT ON EFFORT RELIEVED BY REST OR NITROGLYCERIN.--WITH:
Obstruction or narrowing of coronary vessels observed on angiography obtained independent of social security disability evaluation; OR
Heart enlargement as described under the criteria in §4.02.
RHEUMATIC OR SYPHILITIC HEART DISEASE.--WITH:
Congestive heart failure as described under the criteria in § 4.02; OR
Chest discomfort on effort relieved by rest or nitroglycerin as described under the criteria in §4.08; OR
Chest discomfort on effort, relieved by rest or nitroglycerin, and one of the ECG abnormalities described under the criteria in § 4.06 or §4.07; OR
Heart block or recurrent arrhythmias as described under the criteria in §4.05; OR
Cerebrovascular damage as described under the criteria in §11.04.
Heart enlargement as described under the criteria in §4.02; OR
Right sided congestive failure as evidenced by peripheral edema and liver enlargement and right ventricular enlargement, or outflow tract prominence, on X-ray or fluoroscopy.
ANEURYSM OF AORTA OR BRANCHES (demonstrated by X-ray evidence).--WITH:
Congestive heart failure as described under the criteria in § 4.02; OR
Chest discomfort (with or without effort); OR
Repeated bleeding due to aneurysmal erosion; OR
CHRONIC VENOUS INSUFFICIENCY, LOWER EXTREMITY with chronic obstruction of the deep venous return, superficial varicosities, recurrent ulceration, and extensive brawny edema.
ARTERIOSCLEROSIS OBLITERANS OR THROMBO-ANGIITIS OBLITERANS.--WITH:
Intermittent claudication with absence of peripheral arterial pulsations below the femoral artery or failure of visualization of a major peripheral artery on arteriogram; OR
Amputation at or above the tarsal region due to peripheral vascular disease.
Diseases and disorders of the digestive system resulting in disability usually do so because of interference with nutrition, multiple recurrent inflammatory lesions, or complications of disease; such as, fistulae, abscesses, or recurrent obstruction.
Malnutrition or Weight Loss From Gastrointestinal Disorders. --When the primary disorder of the digestive tract has been established (e.g., entero-colitis, chronic pancreatitis, post gastrointestinal resection, etc.), the resultant interference with nutrition will be considered under the criteria in §5.08. This will apply whether the weight loss is due to a primary or secondary malabsorption or malassimilation syndrome or due to decreased caloric intake. However, weight loss not due to disease of the digestive tract but associated with psychiatric disorders should be evaluated under the appropriate listing for the underlying psychiatric disorder.
A colostomy or ileostomy does not impose marked restriction of activity if the individual is able to maintain adequate nutrition and function of the stoma.
CATEGORY OF IMPAIRMENTS, DIGESTIVE SYSTEM
LOSS OF TONGUE (whole or part)--WITH:
Weight loss or malnutrition as described under the criteria in § 5.08; OR
Inability to communicate by speech.
STRICTURE, STENOSIS, OR OBSTRUCTION OF THE ESOPHAGUS (demonstrated by X-ray or endoscopy) with weight loss or malnutrition as described under the criteria in §5.08.
PEPTIC ULCER INCLUDING RESIDUALS OR COMPLICATIONS (demonstrated by X-ray)--WITH:
Postoperative recurrent ulceration; OR
Fistula formation; OR
Recurrent obstruction demonstrated by X-ray; OR
Weight loss or malnutrition as described under the criteria in § 5.08.
CIRRHOSIS OF LIVER.--WITH:
Ascites, not attributable to other causes, which has been demonstrated by abdominal paracentesis or is associated with serum albumin of 3.0 Gm./100 ml. or less; OR
Serum bilirubin of 2.5 mg./100 ml. or greater or bile in urine (either finding on repeated examinations); OR
Esophageal varices, demonstrated by X-ray or endoscopy, with a documented history of bleeding attributed to these varices or performance of either a shunt operation or a plication of varices; OR
Hepatic coma documented by findings from hospital records.
ULCERATIVE COLITIS (demonstrated by endoscopy or barium enema study)--WITH:
Recurrent bloody stools on repeated examinations and complicated by systemic manifestations; e.g., arthritis, iritis, recurrent fever, or jaundice; OR
Bowel performation with abscess or fistula formation; OR
Recurrent enteritis after total colectomy; OR
Weight loss or malnutrition as described under the criteria in § 5.08.
REGIONAL ENTERITIS (demonstrated by operative findings or small bowel study)--WITH:
Partial intestinal obstruction; OR
Abscess or fistula formation; OR
Weight loss or malnutrition as described under the criteria in § 5.08.
MALNUTRITION (caused by a gastrointestinal impairment resulting from malabsorption, malassimilation, or decreased caloric intake)--WITH:
Weight equal to or less than the values specified in Tables I or II; OR
Weight greater than the values specified in Tables I or II but equal to or less than the values specified in Tables III or IV AND one of the following abnormal test findings:
fat in stool of 7 Gm. or greater per 24-hour stool specimen or decreased absorption of radioactive iodine-labeled fat; OR
nitrogen in stool of 3 Gm. or greater per 24-hour stool specimen or decreased absorption of radioactive labeled protein; OR
abnormally low D-xylose tolerance test in absence of impaired renal function; OR
serum carotene of 45 mcg./100 ml. or less; OR
serum calcium of 8.5 mg./100 ml. or less; OR
serum albumin of 3.0 Gm./100 ml. or less; OR
hematocrit of 34% or below in males or 30% or below in females.
Cardiac or other complications associated with renal disorders may be evaluated according to the appropriate body system listing.
Permanent Urinary Diversion .--It may be necessary to permanently alter the normal course of outflow of urine when disease or trauma destroys portions of the urinary tract. In these cases, evaluation should take into consideration the underlying medical condition as well as the method used in establishing urinary diversion. Significant complications that might result after permanent urinary diversion are in the area of renal impairment such as progressive hydronephrosis.
CATEGORY OF IMPAIRMENTS, GENITO-URINARY SYSTEM
IMPAIRMENT OF RENAL FUNCTION, due to any cause (e.g., hypertensive vascular disease, nephritis, nephrolithiasis, polycystic disease, ureteral obstruction, etc.)--With repeated abnormal renal function tests showing:
BUN of 30 mg./100 ml. or greater (or equivalent elevation of NPN, blood urea, or creatinine); OR
Creatinine clearance equal to or less than 60 liters/24 hours (42 ml./ min.).
REMOVAL OR FUNCTIONAL LOSS OF ONE KIDNEY.-- Evaluate existing disease in the remaining kidney under the criteria in §6.02.
PERMANENT URINARY DIVERSION (e.g., supra-public cystostomy, uretero-intestinal diversion, cutaneous ureterostomy, etc.)--With progressive bilateral hydronephrosis.
TUBERCULOSIS OF THE GENITO-URINARY TRACT.--WITH:
Positive culture of M. tuberculosis more than 3 months following onset of disability; OR
Increasing extent of lesion on cystoscopy or serial pyelography more than 3 months following onset of disability.
HEMIC AND LYMPHATIC SYSTEM
Cause of Disability. --Disability based upon anemia results from inadequate oxygenation of tissues caused by a reduction of the oxygen-carrying capacity of the blood. Hematologic defects can also result in defective hemostatic mechanisms with hemorrhage into such functional components as the brain or major joints or thrombosis of the vascular supply of vital organs. Formation of tumors may cause compression of vital structures or erosion of bone. Deposits of breakdown products of the blood cells may cause impairment of hepatic or renal function, joint deformity, or formation of cholelithiasis with subsequent bile duct obstruction. Where involvement of other organ systems has occurred as a result of hematologic disease, these impairments should be evaluated under the criteria for the appropriate sections.
Red blood cells may be replaced by blood transfusion, but in some diseases this elevation of hematocrit is only transient. A contemplated splenectomy should not, in itself, militate against a finding of disability expected to last at least 12 months.
The level of laboratory findings cited in the categories; i.e., hematocrit, serum bilirubin, reticulocyte and blood platelet count, should reflect the values reported on more than one examination. A single laboratory finding will not suffice to meet the level described.
CATEGORY OF IMPAIRMENTS, HEMIC AND LYMPHATIC SYSTEM
CHRONIC ANEMIA (manifested by hematocrit of 30 percent or less)--Evaluate the resulting impairment or the primary disorder under the criteria for the affected body system.
HEMOLYTIC ANEMIA (due to any cause)--Manifested by hematocrit of 30 percent or less WITH:
Serum bilirubin of 1.5 mg./100 ml. or greater; OR
Reticulocyte count of 4 percent or greater.
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA.-- With hematocrit of 30 percent or less and persistent hemolysis or recurrent crisis.
HEMOGLOBINOPATHIES (e.g., sickle cell disease, thalassemia)--With hematocrit of 30 percent or less and at least one major hemolytic crisis within the 6 months following the onset of disability with a further recorded drop in hematocrit.
PURPURAS (e.g., idiopathic thrombocytopenic purpuras)--WITH:
Persistent purpura and at least one major spontaneous hemorrhage from a body orifice within the 6 months following the onset of disability; OR
Blood platelet count of 40,000/cu. mm. or less.
HEREDITARY TELANGIECTASIA.-- With frequent major hemorrhages from body orifices.
COAGULATION DEFECTS (e.g., deficiency of antihemophilic factor (AHF), plasma thromboplastic component (PTC), plasma thromboplastin antecedent (PTA) or of fibrinogen)--With frequent episodes of spontaneous hemorrhage and hemarthrosis of one major joint with deformity.
POLYCYTHEMIA (secondary and primary manifested by hematocrit of 55 percent or more in males or 50 percent or more in females)--Evaluate the resulting impairment under the criteria for the affected body system.
CHRONIC BONE MARROW FAILURE (aplastic anemia, myelofibrosis, myeloid metaplasia, myelophthisic anemia, etc.)--WITH:
Persistent hematocrit 30 percent or less; OR
Recurrent hemorrhagic manifestations; OR
Blood platelet count of 40,000/cu. mm. or less; OR
Spleen enlarged to iliac crest.
ACUTE LEUKEMIAS.-- With appropriate findings on peripheral blood smear or bone marrow examination.
Persistent hematocrit of 30 percent or less; OR
Recurrent hemorrhagic manifestations; OR
Blood platelet count of 40,000/cu. mm. or less; OR
Massive organ enlargement (e.g., nodes, spleen, or liver) unreduced by prescribed therapy; OR
Recurrent fever (100 degrees F. or above orally).
LYMPHOMAS AND MULTIPLE MYELOMA.-- Evaluate under the criteria for neoplastic diseases in §13.00.
MACROGLOBULINEMIA (diagnosis confirmed by ultracentrifugation or immunoelectrophoresis)--With frequent hemorrhages from body orifices.
Conditions of the skin, including disfiguring scars and repugnant skin disease, will not ordinarily be found in themselves to be disabling. Some skin conditions, such as the ulcerations and eczemas associated with severe varicose veins, or the disfiguring and repugnant skin lesions of certain types of dermatitis, are significant as manifestations of the underlying condition.
Large areas of skin surface are sometimes destroyed by severe burns with consequent scarring and disfigurement. Eventually, factors of contractures and deformities play a significant role in determining functional capacities, and these, in turn, should be evaluated under the criteria in the Musculoskeletal System. (§1.00 ff.)
CATEGORY OF IMPAIRMENTS, THE SKIN
EXFOLIATIVE DERMATITIS (generalized)--In grave and protractive types.
PEMPHIGUS.-- Evaluate under the criteria in §8.02.
Cause of Disability. --Disability is caused by overproduction or underproduction of hormones resulting in structural and/or functional changes in the body. Where involvement of other organ systems has occurred as a result of a primary endocrine disorder, these impairments should be evaluated according to the criteria under the appropriate sections.
CATEGORY OF IMPAIRMENTS, ENDOCRINE
Progressive exophthalmos as measured by exophthalmometry; OR
Evaluate the resulting impairment under the criteria for the affected body system.
Generalized decalcification of bone on X-ray study and elevation of plasma calcium to 11 mg./100 ml. or greater; OR
Evaluate the resulting impairment according to the listing under the affected body system.
Severe recurrent tetany; OR
Recurrent generalized convulsions; OR
Evaluate lenticular cataracts under the criteria in §2.00 ff.
NEUROHYPOPHYSEAL INSUFFICIENCY (diabetes insipidus)--With persistent urine specific gravity of 1.005 or below and dehydration.
HYPERFUNCTION OF THE ADRENAL CORTEX.-- Evaluate the resulting impairment under the criteria for the affected body system.
ADRENAL CORTICAL INSUFFICIENCY (Addison's disease).-- With recurrent episodes of circulatory collapse manifested by hypotensive episodes.
When diabetes exists with other physical or mental impairments, evaluate under the criteria for the appropriate body systems; OR
Diabetes with one of the following (not covered under existing body system listing):
neuropathy with moderate motor deficit in two extremities; OR
acidosis occurring at least on the average of once every two months, documented by appropriate blood chemical tests (pH or pCO2 or bicarbonate levels); OR
amputation at, or above, the tarsal region due to diabetic necrosis or peripheral vascular disease; OR
ophthalmologic findings of:
retinitis proliferans; OR
rubeosis iridis; OR
venous distention and capillary pattern distortion with hemorrhages or exudates.
MULTIPLE BODY SYSTEMS
Introduction .--The impairments included in this section usually involve more than a single body system. For the categories of miliary tuberculosis and tuberculous adenitis, the existence of tubercle bacilli must be established in accordance with the criteria in §3.00 B.
CATEGORY OF IMPAIRMENTS, MULTIPLE BODY SYSTEMS
HANSEN'S DISEASE (leprosy)-- As active disease or consider as “under a disability” while hospitalized.
POLYARTERITIS OR PERIARTERITIS
NODOSA (established by biopsy)--With signs of generalized arterial involvement.
DISSEMINATED LUPUS ERYTHEMATOSUS (established by a positive LE preparation or biopsy)--With frequent exacerbations demonstrating involvement of renal or cardiac or pulmonary or gastrointestinal or central nervous systems.
SCLERODERMA OR PROGRESSIVE
SYSTEMIC SCLEROSIS (the diffuse or generalized form).--WITH:
Advanced limitation of use of hands due to sclerodactylia or limitation in other joints; OR
Visceral manifestations of digestive, cardiac, or pulmonary impairment.
Demonstration of tubercle bacilli - more than 3 months folowing the onset of disability; OR
Evaluate the residual impairment under the criteria for the affected body system.
Demonstration of tubercle bacilli more than 3 months following the onset of disability; OR
Other evidence of increasing extent of lesion more than 3 months following the onset of disability.
Epilepsy. --Epilepsy must be substantiated at least one detailed description of a typical seizure, preferably one observed and reported by a physician. Testimony of reliable lay persons may be acceptable for description of seizures only if professional observation is not available. Documentation of epilepsy should include an electroencephalogram (EEG). The severity of the impairment will be determined according to the frequency, duration, and sequelae of seizures. Where adequate seizure control is obtained only with unusually large doses of medication, consideration will be given to any impairment resulting from the side effects of this medication.
Brain Tumors. --The diagnosis in malignant brain tumor should be established under the criteria described in §13.00 B., for Neoplastic Diseases.
CATEGORY OF IMPAIRMENTS, NEUROLOGICAL
EPILEPSY--MAJOR MOTOR SEZURES (grand mal or psychomotor) substantiated by EEG, occurring more frequently than once a month in spite of prescribed treatment--WITH:
Diurnal episodes (loss of consciousness and convulsive seizure); OR
Nocturnal episodes which show residuals interfering with activity during the day.
EPILEPSY--MINOR MOTOR SEIZURES (petit mal or psychomotor) substantiated by EEG, occurring more frequently than once weekly in spite of prescribed treatment--WITH:
Alteration of awareness or loss of consciousness; AND
Transient postictal manifestations of unconventional or antisocial behavior.
CEREBROVASCULAR ACCIDENT.-- With ONE of the following more than 4 months Post-CVA:
Sensory or motor aphasia resulting in ineffective speech or communication; OR
Pseudobulbar palsy; OR
Moderate motor deficit in two extremities; OR
Ataxia affecting two extremities substantiated by appropriate cerebellar signs or
Malignant gliomas (astrocytoma--Grades III and IV, glioblastoma multiforme), medulloblastoma, ependymoblastoma, or primary sarcoma; OR
Evaluate astrocytoma (Grades I and II), pituitary tumors, oligodendroglioma, ependymoma, clivus chordoma, and benign tumors under the criteria in §11.02, §11.03, or §11.04A, C or D.
PARALYSIS AGITANS (Parkinson's disease)-- With tremor, rigidity, and impairment of mobility (e.g., festination).
I.Q. of 69 or less; OR
Abnormal behavior patterns, such as destructiveness or emotional instability; OR
Significant interference in communication due to speech, hearing, or visual defect; OR
Moderate motor deficit in two extremities.
SPINAL CORD LESIONS, due to any cause.--With moderate motor loss in two extremities.
Moderate motor deficits in two extremities; OR
Ataxia substantiated by appropriate cerebellar signs or proprioceptive loss.
AMYOTROPHIC LATERAL SCLEROSIS OR SYRINGOMYELIA.--WITH:
Bulbar signs; OR
Moderate motor (or sensory, if applicable) deficit in two extremities.
Flexion contractures as described under the criteria in §1.09; OR
Respiratory distress or dysphagia; OR
Moderate motor weakness in two extremities.
Difficulty in speaking or swallowing while on prescribed therapy; OR
Motor weakness of muscles of extremities on repetitive activity against resistance while on prescribed therapy.
Waddling or incoordinate gait; OR
Flexion deformities of both lower extremities; OR
Weakness or paralysis of muscles of shoulder girdle or of neck, with abduction of both arms at shoulder restricted to less than 90 degrees.
PERIPHERAL NEUROPATHIES.-- With moderate motor deficit in two extremities.
Tabetic crises occurring more frequently than once monthly; OR
Unsteady, broad-based, or ataxic gait substantiated by appropriate posterior column signs; OR
Charcot joint as described under the criteria in §1.03.
SUBACUTE COMBINED CORD DEGENERATION (pernicious anemia).--WITH:
Moderate motor deficit in two extremities; OR
Unsteady, broad-based, or ataxic gait substantiated by appropriate posterior column signs.
DEGENERATIVE DISEASES (Huntington's chorea, Friedreich's ataxia, spino-cerebellar degenerations).
Introduction. --For the purpose of the social security program, mental disorders will be considered in three group entities: organic brain syndromes, functional disorders, and mental deficiency.
Discussion of Mental Disorders
Organic brain syndromes are disorders caused by, or associated with, impairment of brain tissue.
Acute brain syndromes are mentioned for explanatory purposes only since their duration is too short to assume adjudicative significance. They are temporary and reversible conditions with favorable prognosis and no significant residuals. They are short-lived and self-limited. Occasionally, an acute brain syndrome may progress into a chronic brain syndrome.
Chronic brain syndromes result from persistent, more or less irreversible diffuse impairment of cerebral tissue function. They are usually permanent and may be progressive. They may be accompanied by psychotic or neurotic reactions superimposed on the organic brain pathology. The degree of impairment may range from mild to severe.
The individual's personal appearance and behavior at the time of the examination, his daily activities, interests, and habits generally reflect the severity of the impairment and are, therefore, very important in the evaluation process.
Functional mental disorders are characterized by demonstrable mental abnormalities without demonstrable structural changes in the brain tissue.
Psychotic Disorders. --Mood disorders (involutional psychotic, manic-depressive, psychotic depressive reactions) and thought disorders (schizophrenic and paranoid reactions) are characterized by varying degrees of personality disorganization and accompanied by a corresponding degree of inability to maintain contact with reality (e.g., hallucinations, delusions).
Nonpsychotic Disorders (psychophysiologic, psychoneurotic and personality disorders).--
Psychophysiologic autonomic and visceral disorders (e.g., cardiovascular, gastrointestinal, genito-urinary, musculoskeletal, respiratory). In these disorders, the normal physiological expression of emotions is exaggerated by chronic emotional tensions, eventually leading to a disruption of the autonomic regulatory system, resulting in various visceral disorders. If the condition persists, it may lead to demonstrable structural changes (e.g., peptic ulcer, bronchial asthma, dermatitis).
Psychoneurotic disorders (anxiety reaction, neurotic-depressive reaction, conversion reaction, dissociative reaction, obsessive-compulsive reaction, phobias). There are no gross falsifications of reality such as observed in the psychoses in the form of hallucinations or delusions. Psychoneuroses are characterized by reactions to deep-seated conflicts and are classified by the defense mechanisms the individual employs to stave off the threat of emotional decompensation (e.g., anxiety, depression, conversion, obsessive-compulsive or phobic mechanisms). Anxiety or depression occurring in connection with overwhelming external situations (i.e., situational reactions) are self-limited, and the symptoms generally recede when the situational stress diminishes.
Personality disorders (inadequate, schizoid, cyclothymic, paranoid personalities; emotional instability, passive-aggressive and passive-dependent behavior; compulsive personality; antisocial behavior, sexual deviations, addictions). These disorders or defects in personality structure are often characterized by lifelong patterns of inadequate or socially
Mental deficiency denotes a lifelong disorder characterized by below-average intellectual endowment as measured by standard intelligence (IQ) tests and associated with impairment in one or more of the following areas: learning, maturation, and social adjustment.
The following paragraphs discuss evidence required in cases involving mental deficiency:
In mental deficiency, the degree of impairment should be determined primarily on the basis of the IQ and the medical report. Intelligence tests should be administered and interpreted by a qualified psychologist or psychiatrist using standardized intelligence tests such as the Wechsler Adult Intelligence Scale (WAIS). In special circumstances, nonverbal performance tests, such as the Raven Progressive Matrices or the Arthur Point Scale, may be substituted. However, identical IQ scores obtained from different tests do not always reflect a similar degree of intellectual function. Therefore, it may be necessary to convert the IQ to the percentile rank of the general population in order to determine the actual degree of impairment reflected by the IQ score. In communities where a qualified psychologist or psychiatrist is not readily available, an intelligence test administered by a vocational rehabilitation counselor or a specially trained person associated with a local school system may be accepted, particularly when other findings are also consistent with extremely low intellectual capacity.
In cases where, in the opinion of the psychological examiner, the nature of the individual's performance is such that testing, as described above, is precluded or cannot otherwise be obtained, medical reports specifically describing the level of intellectual, social, and physical function should be obtained. Actual observations by district office or State agency personnel, reports from educational institutions, information furnished by public welfare agencies or other reliable, objective sources should be considered as additional evidence.
Documentation. --The severity of a mental disorder should be evaluated on the basis of psychiatrists' reports, hospital reports, psychologists' reports and descriptions of daily activities
Confinement in an institution does not establish that an impairment is severe. Also, release from an institution does not establish improvement. The severity and duration of the impairment is determined by the medical evidence.
In some cases, the results of standard psychological tests, such as the Wechsler Adult Intelligence Scale (WAIS) and the Minnesota Multiphasic Personality Inventory (MMPI), may be of considerable value in making a differential diagnosis and in establishing the severity of the impairment. To provide full documentation, the psychological report should include key data upon which the report was based, such as MMPI profiles, WAIS subtest scores, etc.
CATEGORY OF IMPAIRMENTS, MENTAL DISORDERS
CHRONIC BRAIN SYNDROMES, documented by mental status examination (supported, if necessary, by the results of appropriate, standardized psychological tests) establishing deterioration in intellectual functioning and manifested by marked restriction of daily activities and constriction of interests and deterioration in personal habits and seriously impaired ability to relate to other people and persistence of ONE of the following:
Marked memory defect for recent events; OR
Impoverished, slowed, perseverative thinking, with confusion or disorientation; OR
Labile, shallow, or coarse affect.
FUNCTIONAL PSYCHOTIC DISORDERS (mood disorders, schizophrenic reactions, paranoid reactions) manifested by marked restrictions of daily activities and constriction of interests and seriously impaired ability to relate to other people, and persistence of ONE of the following:
Depression (or elation); OR
Psychomotor disturbances; OR
Hallucinations or delusions; OR
Autistic or other regressive behavior; OR
Inappropriateness of affect; OR
Illogical association of ideas.
NOTE: Listing 12.04 as shown here and on the following page was in effect from August 1968 through September 1975.
FUNCTIONAL NON-PSYCHOTIC DISORDERS (psychophysiologic, psychoneurotic and personality disorders) manifested by marked restriction of daily activities and constriction of interests and deterioration in personal habits and seriously impaired ability to relate to other people and persistence of ONE of the following:
Demonstrable structural changes mediated through psychophysiological channels (e.g., duodenal ulcer); OR
Recurrent and persistent periods of anxiety, with tension, apprehension, and interference with concentration and memory; OR
Persistent depressive affect with insomnia, loss of weight, and suicidal ideation; OR
Phobic or obsessive ruminations with inappropriate, bizarre or disruptive behavior; OR
Compulsive, ritualistic behavior; OR
Persistent functional disturbance of vision, speech, hearing or use of a limb with demonstrable structural or trophic changes; OR
Life-long, habitual, and inappropriate patterns of behavior manifested by one of the following:
seclusiveness and autistic thinking; OR
antisocial or amoral behavior (including pathologic sexuality) manifested by: (a) inability to learn from experience and inability to conform with accepted social standards, leading to repeated conflicts with society or authority and (b) by psychopathology documented by mental status examination and the results of appropriate, standardized psychological tests; OR
addictive dependence on alcohol or drugs, with evidence of irreversible organ damage; OR
pathologically inappropriate suspiciousness or hostility manifested by psychopathology documented by mental status examination and the results of appropriate, standardized psychological tests.
FUNCTIONAL NONPSYCHOTIC DISORDERS (psychophysiologic, psychoneurotic and personality disorders, drug addiction and alcoholism). Manifested by marked restriction of daily activities and constriction of interests and deterioration in personal habits and seriously impaired ability to relate to other people and persistence of ONE of the following:
Demonstrable structural changes mediated through psychophysiological channels (e.g., duodenal ulcer); OR
Recurrent and persistent periods of anxiety; with tension, apprehension, and interference with concentration and memory; OR
Persistent depressive affect with insomnia, loss of weight, and suicidal ideation; OR
Phobic or obsessive ruminations with inappropriate, bizarre, or disruptive behavior; OR
Compulsive, ritualistic behavior, OR
Persistent functional disturbance of vision, speech, hearing, or use of a limb with demonstrable structural or trophic changes; OR
Long-lasting, habitual, and inappropriate patterns of behavior manifested by one of the following:
Seclusiveness and autistic thinking; OR
Antisocial or amoral behavior (including pathologic sexuality) manifested by: (a) inability to learn from experience and inability to conform with accepted social standards, leading to repeated conflicts with society or authority and (b) by psychopathology documented by mental status examination and the results of appropriate, standardized psychological tests; OR
Pathologically inappropriate suspiciousness or hostility manifested by psychopathology documented by mental status examination and the results of appropriate, standardized psychological tests.
MENTAL DEFICIENCY as manifested by:
Severe mental and social incapacity as evidenced by marked dependence upon others for personal needs (e.g., bathing, washing, dressing, etc.) and inability to understand the spoken word and inability to avoid physical danger (fire, cars, etc.) and inability to follow simple directions and inability to read, write, and perform simple calculations; OR
I.Q. of 49 or less (see §12.00 C.1.); OR
I.Q. of 50 to 69, inclusive (see §12.00 C.1.) AND:
inability to perform routine, repetitive tasks; OR
a physical or other mental impairment resulting in restriction of function.
Introduction. --The determination of the level of severity resulting from cancer is made from a consideration of the site of the lesion, the histogenesis of the tumor, the extent of involvement, the apparent adequacy and response to therapy (surgery, irradiation, hormones, chemotherapy), and the magnitude of the post-therapeutic residuals.
Significant post-therapeutic residuals, not specifically included in the category of impairments for malignant neoplasms, should be evaluated according to the affected body system.
Documentation. --The diagnosis of cancer should be established on the basis of symptoms, signs and laboratory findings. The site of the primary, recurrent and metastatic lesion must be specified in all cases of malignant neoplastic diseases. If an operative procedure has been performed, the evidence should include a copy of the operative note and the report of the gross and microscopic examination of the surgical specimen. The evidence should include also a recent report directed especially at revealing evidence of local or regional recurrence, soft part or skeletal metastasis and significant post-therapeutic residuals.
Evaluation. --Usually, when the cancer consists only of a local lesion with metastasis to the regional lymph nodes which apparently has been completely excised, imminent recurrence or metastasis is not anticipated. Exceptions are noted in sections 13.03, 13.05B, 13.09B, 13.09D, 13.10A, 13.11A-F, 13.17C, 13.22A-B, and 13.24A.
Local or regional recurrence after radical surgery or pathological evidence of incomplete excision by radical surgery are to be equated with unresectable lesions and, for the purpose of our program may be evaluated as “inoperable.” These situations are usually followed by severe impairment within six months to one year. A severe impairment may usually be determined to exist, because the curtailment of activities is imminent.
Local or regional recurrence after incomplete excision of a localized, completely resectable tumor is not to be equated with recurrence after radical surgery.
When a cancer has metastasized beyond the regional lymph nodes the impairment is severe and usually terminates fatally within a short time despite palliative therapy. Exceptions are partially hormone-dependent tumors; isotope-sensitive metastases; or remote metastases which have not been apparent for five or more years.
CATEGORY OF IMPAIRMENTS, NEOPLASTIC DISEASES--MALIGNANT
EPIDERMOID CARCINOMA (including lympho-epithelioma of base of tongue, pharynx and tonsil)--
Inoperable or recurrent after radical surgery; OR
SARCOMA OF SKIN--ANGIOSARCOMA OR MYCOSIS FUNGOIDES with metastasis to regional lymph nodes or beyond.
SARCOMA OF SOFT PARTS.--
Not controlled by prescribed therapy; OR
Cellular sarcoma with remote metastasis.
Recurrent after excision; OR
With metastasis to adjacent skin or regional lymph nodes or elsewhere.
Hodgkins disease, lymphosarcoma or giant follicular lymphoblastoma--not controlled by prescribed therapy or with evidence of mediastinal, pelvic, abdominal, retroperitioneal or skeletal extension from peripheral lymph nodes; OR
Metastasis from distant carcinoma; OR
Lymph nodes site of unresectable carcinoma.
SALIVARY GLANDS--CARCINOMA OR
SARCOMA with metastasis beyond the regional lymph nodes.
THYROID GLAND--CARCINOMA with metastasis beyond the regional lymph nodes not controlled by prescribed therapy.
Inoperable carcinoma including acute (inflammatory) carcinoma; OR
Recurrent carcinoma; OR
Remote metastasis from breast carcinoma (Bilateral breast carcinoma, synchronous or metachronous, is usually primary in each breast.); OR
Sarcoma with metastasis anywhere.
SKELETAL SYSTEM (exclusive of the jaw)--
Osteogenic sarcoma, Ewing's tumor, reticulum cell sarcoma with evidence of metastasis; OR
Multiple or diffuse myeloma; OR
Metastatic carcinoma to bone (except those originating in thyroid or prostate, evaluate under the criteria in §13.08 or §13.23).
MANDIBLE, MAXILLA, ORBIT, OR
Sarcoma of any type with metastasis; OR
Carcinoma of the antrum with extension into the orbit, or ethmoid or sphenoid sinus, or with regional or remot metastasis; OR
Orbital tumors with intracranial extension; OR
Tumors of the temporal fossa with perforation of skull and meningeal involvement; OR
Adamantinoma with orbital or intracranial infiltration; OR
Tumors of Rathke's pouch with infiltration of the base of the skull or bilateral metastasis to the cervical lymph nodes or remote metastasis.
BRAIN OR SPINAL CORD.--
Metastatic carcinoma to brain or spinal cord.
Evaluate other tumors under the criteria described in §11.05 and §11.08.
LUNGS--BRONCHOGENIC CARCINOMA OR ADENOCARCINOMA.--
Recurrent after resection; OR
Incomplete excision; OR
Infiltration of the chest wall or preoperative pleural effusion or remote metastasis; OR
Metastatic carcinoma or sarcoma to the lungs (except metastasis from thyroid, evaluate under the criteria in §13.08).
PLEURA OR MEDIASTINUM.--
Pleural mesothelioma, with pleural effusion or remote metastasis; OR
All primary or metastatic tumors of the anterior mediastinum (except thyroid or parathyroid tumors and benign thymoma and primary Hodgkins disease); OR
Metastatic carcinoma or sarcoma to the pleura or mediastinum (except metastasis from thyroid, evaluate under the criteria in §13.08).
Generalized carcinomatosis; OR
Retroperitoneal cellular sarcoma; OR
Unresectable benign fibromyxoma of nerve sheath.
ESOPHAGUS OR STOMACH.--
Carcinoma or sarcoma of the upper two-thirds of the esophagus; OR
Carcinoma or sarcoma, of the distal one-third of the esophagus with metastasis beyond the regional lymph nodes; OR
Carcinoma of the stomach with either metastasis beyond the regional lymph nodes or extension into the colon, pancreas or liver; OR
Inoperable carcinoma; OR
Recurrence or metastasis after resection; OR
Carcinoma or carcinoid tumor with metastasis beyond the regional lymph nodes; OR
Multiple sarcomas; OR
Sarcoma with metastasis.
LARGE INTESTINE (from ileocecal valve to and including anal canal)--CARCINOMA OR SARCOMA.--
Metastasis beyond the regional lymph nodes; OR
Recurrence, or remote metastasis, after resection.
LIVER OR GALLBLADDER.--
Primary or metastatic carcinoma, carcinoid tumor or sarcoma of the liver; OR
Carcinoma of the gallbladder or bile duct when unresectable or there is direct extension into the liver.
PANCREAS.-- Carcinoma in any location.
KIDNEYS, ADRENAL GLANDS, OR URETERS--CARCINOMA.--
Unresectable or with metastasis; OR
Metastatic carcinoma to a kidney, adrenal gland, or ureter.
Infiltration beyond the bladder wall; OR
Recurrence after total cystectomy; OR
Evaluate urinary diversion after total cystectomy under the criteria in §6.04.
PROSTATE GLAND.-- Carcinoma not controlled by prescribed therapy.
Chriocarcinoma with metastasis even to regional lymph nodes; OR
Other malignant tumors with metastasis beyond the para-aortic lymph nodes or when metastasis to the para-aortic lymph nodes are unresectable or not controlled by prescribed therapy.
UTERUS--CARCINOMA OR SARCOMA (fundus or cervix)--
Inoperable and not controlled by prescribed therapy; OR
Recurrent, after total hysterectomy; OR
Total pelvic exenteration.
OVARY OR FALLOPIAN TUBES--ALL MALIGNANT PRIMARY OR RECURRENT TUMORS.--WITH:
Unresectable infiltration; OR
Unresectable metastasis to omentum or elsewhere in the peritoneal cavity; OR
Remote metastasis; OR
All metastatic tumors to ovary or Fallopian tubes.
LEUKEMIA.-- Evaluate under the criteria in §7.00 ff., Hemic and Lymphatic System.