DI 34131.011 Neurological Listings from 08/28/03 to 12/14/04
A. Epilepsy. In epilepsy, regardless of etiology, degree of impairment will be determined according
to type, frequency, duration, and sequelae of seizures. At least one detailed description
of a typical seizure is required. Such description includes the presence or absence
of aura, tongue bites, sphincter control, injuries associated with the attack, and
postictal phenomena. The reporting physician should indicate the extent to which description
of seizures reflects his own observations and the source of ancillary information.
Testimony of persons other than the claimant is essential for description of type
and frequency of seizures if professional observation is not available.
Under 11.02 and 11.03, the criteria can be applied only if the impairment persists
despite the fact that the individual is following prescribed antiepileptic treatment.
Adherence to prescribed antiepileptic therapy can ordinarily be determined from objective
clinical findings in the report of the physician currently providing treatment for
epilepsy. Determination of blood levels of phenytoin sodium or other antiepileptic
drugs may serve to indicate whether the prescribed medication is being taken. When
seizures are occurring at the frequency stated in 11.02 or 11.03, evaluation of the
severity of the impairment must include consideration of the serum drug levels. Should
serum drug levels appear therapeutically inadequate, consideration should be given
as to whether this is caused by individual idiosyncrasy in absorption or metabolism
of the drug. Blood drug levels should be evaluated in conjunction with all other evidence
to determine the extent of compliance. When reported blood drug levels are low, therefore,
the information obtained from the treating source should include the physician's statement
as to why the levels are low and the results of any relevant diagnostic studies concerning
the blood levels. Where adequate seizure control is obtained only with unusually large
doses, the possibility of impairment resulting from the side effects of this medication
must also be assessed. Where documentation shows that use of alcohol or drugs affects
adherence to prescribed therapy or may play a part in the precipitation of seizures,
this must also be considered in the overall assessment of impairment level. (See DI 24580.001 .)
B. Brain tumors. The diagnosis of malignant brain tumors must be established, and the persistence
of the tumor should be evaluated, under the criteria described in 13.00B and C for
In histologically malignant tumors, the pathological diagnosis alone will be the decisive
criterion for severity and expected duration (see 11.05A). For other tumors of the
brain, the severity and duration of the impairment will be determined on the basis
of symptoms, signs, and pertinent laboratory findings(11.05B).
C. Persistent disorganization of motor function in the form of paresis or paralysis, tremor or other involuntary movements, ataxia
and sensory disturbances (any or all of which may be due to cerebral, cerebellar,
brain stem, spinal cord, or peripheral nerve dysfunction) which occur singly or in
various combinations, frequently provides the sole or partial basis for decision in
cases of neurological impairment. The assessment of impairment depends on the degree
of interference with locomotion and/or interference with the use of fingers, hands
D. In conditions which are episodic in character, such as multiple sclerosis or myasthenia gravis, consideration should be given to
frequency and duration of exacerbations, length of remissions, and permanent residuals.
E. Multiple sclerosis. The major criteria for evaluating impairment caused by multiple sclerosis are discussed
in Listing 11.09. Paragraph A provides criteria for evaluating disorganization of
motor function and gives reference to 11.04B (11.04B then refers to 11.00C). Paragraph
B provides references to other listings for evaluating visual or mental impairments
caused by multiple sclerosis. Paragraph C provides criteria for evaluating the impairment
of individuals who do not have muscle weakness or other significant disorganization
of motor function at rest, but who do develop muscle weakness on activity as a result
Use of the criteria in 11.09C is dependent upon (1) documenting a diagnosis of multiple
sclerosis, (2) obtaining a description of fatigue considered to be characteristic
of multiple sclerosis, and (3) obtaining evidence that the system has actually become
fatigued. The evaluation of the magnitude of the impairment must consider the degree
of exercise and the severity of the resulting muscle weakness.
The criteria in 11.09C deals with motor abnormalities which occur on activity. If
the disorganization of motor function is present at rest, paragraph A must be used,
taking into account any further increase in muscle weakness resulting from activity.
Sensory abnormalities may occur, particularly involving central visual acuity. The
decrease in visual acuity may occur after brief attempts at activity involving near
vision, such as reading. This decrease in visual acuity may not persist when the specific
activity is terminated, as with rest, but is predictably reproduced with resumption
of the activity. The impairment of central visual acuity in these cases should be
evaluated under the criteria in Listing 2.02, taking into account the fact that the
decrease in visual acuity will wax and wane.
Clarification of the evidence regarding central nervous system dysfunction responsible
for the symptoms may require supporting technical evidence of functional impairment
such as evoked response tests during exercise.
F. Traumatic brain injury (TBI). The guidelines for evaluating impairments caused by cerebral trauma are contained
in 11.18. Listing 11.18 states that cerebral trauma is to be evaluated under 11.02,
11.03, 11.04, and 12.02, as applicable.
TBI may result in neurological and mental impairments with a wide variety of posttraumatic
symptoms and signs. The rate and extent of recovery can be highly variable and the
long-term outcome may be difficult to predict in the first few months post-injury.
Generally, the neurological impairment (s) will stabilize more rapidly than any mental
impairment (s). Sometimes a mental impairment may appear to improve immediately following
TBI and then worsen, or, conversely, it may appear much worse initially but improve
after a few months. Therefore, the mental findings immediately following TBI may not
reflect the actual severity of your mental impairment (s). The actual severity of
a mental impairment may not become apparent until 6 months post-injury.
In some cases, evidence of a profound neurological impairment is sufficient to permit
a finding of disability within 3 months post-injury. If a finding of disability within
3 months post-injury is not possible based on any neurological impairment (s), we
will defer adjudication of the claim until we obtain evidence of your neurological
or mental impairments at least 3 months post-injury. If a finding of disability still
is not possible at that time, we will again defer adjudication of the claim until
we obtain evidence at least 6 months post-injury. At that time, we will fully evaluate
any neurological and mental impairments and adjudicate the claim.
G. Amyotrophic Lateral Sclerosis (ALS). 1. Amyotrophic lateral sclerosis (ALS), sometimes called Lou Gehrig's disease, is
a progressive, invariably fatal neurological disease that attacks the nerve cells
(motor neurons) responsible for controlling voluntary muscles. Eventually, all muscles
under voluntary control are affected, and individuals with ALS ultimately lose their
ability to move their arms and legs, and their capacity to swallow, speak, and breath.
Most people with ALS die from respiratory failure. There is currently no cure for
ALS, and most treatments are designed only to relieve symptoms and improve the quality
2. Diagnosis of ALS is based on history, neurological findings consistent with the
diagnosis of ALS, and electrophysiological and neuroimaging testing to rule out other
impairments that may cause similar signs and symptoms. The diagnosis may also be supported
by electrophysiological studies (electromyography or nerve conduction studies), but
these tests may be negative or only suggestive of the diagnosis. There is no single
test that establishes the existence of ALS.
3. For purposes of 11.10, documentation of the diagnosis must be by generally accepted
methods consistent with the prevailing state of medical knowledge and clinical practice.
The evidence should include documentation of a clinically appropriate medical history,
neurological findings consistent with the diagnosis of ALS, and the results of any
electrophysiological and neuroimaging testing.
11.01 Category of Impairments, Neurological
11.02 Epilepsy—convulsive epilepsy (grand mal or psychomotor), documented by detailed description of a typical seizure
pattern, including all associated phenomena; occurring more frequently than once
a month, in spite of at least 3 months of prescribed treatment. With:
A. Daytime episodes (loss of consciousness and convulsive seizures); or
B. Nocturnal episodes manifesting residuals which interfere significantly with activity
during the day. (See DI 24580.001 .)
11.03 Epilepsy—non-convulsive epilepsy (petit mal, psychomotor, or focal), documented by detailed description of a typical
seizure pattern, including all associated phenomena; occurring more frequently than
once weekly in spite of at least 3 months of prescribed treatment. With alteration
of awareness or loss of consciousness and transient postictal manifestations of unconventional
behavior or significant interference with activity during the day. (See DI 24580.001
11.04 Central nervous system vascular accident. With one of the following more than 3 months postvascular accident:
A. Sensory or motor aphasia resulting in ineffective speech or communication; or
B. Significant and persistent disorganization of motor function in two extremities,
resulting in sustained disturbance of gross and dexterous movements, or gait and station
(see 11.00C). (See DI 24580.010 .)
11.05 Brain tumors.
A. Malignant gliomas (astrocytoma—grades III and IV, glioblastoma multiforme), medulloblastoma,
ependymoblastoma, or primary sarcoma; or
B. Astrocytoma (grades I and II), meningioma, pituitary tumors, oligodendroglioma,
ependymoma, clivus chordoma, and benign tumors. Evaluate under 11.02, 11.03, 11.04A
or B, or 12.02.
11.06 Parkinsonian syndrome. With the following signs: Significant rigidity, bradykinesia, or tremor in two extremities,
which, singly or in combination, result in sustained disturbance of gross and dexterous
movements, or gait and station.
11.07 Cerebral palsy. With:
A. IQ of 70 or less; or
B. Abnormal behavior patterns, such as destructiveness or emotional instability; or
C. Significant interference in communication due to speech, hearing, or visual defect;
D. Disorganization of motor function as described in 11.04B.
11.08 Spinal cord or nerve root lesions, due to any cause. With disorganization of motor function as described in 11.04B.
11.09 Multiple sclerosis. (see DI24580.015
A. Disorganization of motor function as described in 11.04B; or
B. Visual or mental impairment as described under the criteria in 2.02, 2.03, 2.04,
or 12.02; or
C. Significant, reproducible fatigue of motor function with substantial muscle weakness
on repetitive activity, demonstrated on physical examination, resulting from neurological
dysfunction in areas of the central nervous system known to be pathologically involved
by the multiple sclerosis process.
11.10 Amyotrophic lateral sclerosis established by clinical and laboratory findings, as described in 11.00G. (See DI 24580.020 .)
11.11 Anterior poliomyelitis. With:
A. Persistent difficulty with swallowing or breathing; or
B. Unintelligible speech; or
C. Disorganization of motor function as described in 11.04B.
11.12 Myasthenia gravis. With:
A. Significant difficulty with speaking, swallowing, or breathing while on prescribed
B. Significant motor weakness of muscles of extremities on repetitive activity against
resistance while on prescribed therapy.
11.13 Muscular dystrophy. With disorganization of motor function as described in 11.04B.
11.14 Peripheral neuropathies. With disorganization of motor function as described in 11.04B, in spite of prescribed
11.16 Subacute combined cord degeneration (pernicious anemia). With disorganization of motor function as described in 11.04B,
not significantly improved by prescribed treatment.
11.17 Degenerative disease not listed elsewhere, such as Huntington's chorea, Friedreich's ataxia, and spino-cerebellar
A. Disorganization of motor function as described in 11.04B; or
B. Chronic brain syndrome. Evaluate under 12.02.
11.18 Cerebral trauma. Evaluate under the provisions of 11.02, 11.03, 11.04, and 12.02, as applicable.
11.19 Syringomyelia. With:
A. Significant bulbar signs; or
B. Disorganization of motor function as described in 11.04B.