Basic (04-86)

DI 34205.001 Listing of Impairments - Part B (March 16, 1977-January 5, 1986)

 

100.00 Growth Impairment

A. Impairment of Growth

Impairment of growth may be disabling in itself or it may be an indicator of the severity of the impairment due to a specific disease process.

Determinations of growth impairment should be based upon the comparison of current height with at least three previous determinations, including length at birth, if available. Heights (or lengths) should be plotted on a standard growth chart, such as derived from the National Center for Health Statistics: NCHS Growth Charts. Height should be measured without shoes. Body weight corresponding to the ages represented by the heights should be furnished. The adult heights of the child's natural parents and the heights and ages of siblings should also be furnished. This will provide a basis upon which to identify those children whose short stature represents a familial characteristic rather than a result of disease. This is particularly true for adjudication under 100.02B.

B. Bone Age Determinations

Bone age determinations should include a full descriptive report of roentgenograms specifically obtained to determine bone age and must cite the standardization method used. Where roentgenograms must be obtained currently as a basis for adjudication under 100.03, views of the left hand and wrist should be ordered. In addition, roentgenograms of the knee and ankle should be obtained when cessation of growth is being evaluated in an older child at, or past, puberty.

C. Application of Criteria

The criteria in this section are applicable until closure of the major epiphyses. The cessation of significant increase in height at that point would prevent the application of these criteria.

 

100.01 Category of Impairments, Growth

 

100.02 Growth Impairment, considered to be related to an additional specific medically determinable impairment, and ONE of the following:

1. A. 

   Fall of greater than 15 percentiles in height which is sustained; OR

2. B. 

   Fall to, or persistence of, height below the third percentile.

    

100.03 Growth Impairment, not identified as being related to an additional, specific medically determinable impairment. With:

1. A. 

   Fall of greater than 25 percentiles in height which is sustained; AND

2. B. 

   Bone age greater than two standard deviations (2 SD) below the mean for chronological age (see 100.00B).

    

101.00 Musculoskeletal System

A. Documentation of Rheumatoid Arthritis

Documentation of the diagnosis of juvenile rheumatoid arthritis should be made according to an established protocol, such as that published by the Arthritis Foundation, Bulletin on the Rheumatic Diseases, Vol. 23, 1972-1973 Series, p. 712. Inflammatory signs include persistent pain, tenderness, erythema, swelling, and increased local temperature of a joint.

B. Measurements of Joint Motion

The measurements of joint motion are based on the technique for measurements described in the “Joint Method of Measuring and Recording,” published by the American Academy of Orthopedic Surgeons in 1965, or “The Extremities and Back” in “Guides to the Evaluation of Permanent Impairment,” Chicago, American Medical Association, 1971 Chapter 1, pp. 1-48.

C. Degenerative Arthritis

Degenerative arthritis may be the end stage of many skeletal diseases and conditions, such as traumatic arthritis, collagen disorders, septic arthritis, congenital dislocation of the hip, aseptic necrosis of the hip, slipped capital femoral epiphyses, skeletal dysplasias, etc.

 

101.01 Category of Impairments, Musculoskeletal

 

101.02 Juvenile Rheumatoid Arthritis With:

1. A. 

   Persistence or recurrence of joint inflammation despite six months of medical treatment and ONE of the following:

   1. 1. 

      Limitation of motion of two major joints of 50 percent or greater; OR

   2. 2. 

      Fixed deformity of two major weight-bearing joints of 30 degrees or more; OR

   3. 3. 

      Radiographic changes of joint narrowing, erosion, or subluxation; OR

   4. 4. 

      Persistent or recurrent systemic involvement such as iridocyclitis or pericarditis; OR

2. B. 

   Steroid dependence.

    

101.03 Deficit of Musculoskeletal Function

Due to deformity or musculoskeletal disease and ONE of the following:

1. A. 

   Walking is markedly reduced in speed or distance despite orthotic or prosthetic devices; OR

2. B. 

   Ambulation is possible only with obligatory bilateral upper limb assistance (e.g., with walker, crutches); OR

3. C. 

   Inability to perform age-related personal self-care activities involving feeding, dressing, and personal hygiene.

101.05 Disorders of the Spine

1. A. 

   Fracture of vertebra with cord involvement (substantiated by appropriate sensory and motor loss); OR

2. B. 

   Scoliosis (congenital idiopathic or neuromyopathic). With:

   1. 1. 

      Major spinal curve measuring 60 degrees or greater; OR

   2. 2. 

      Spinal fusion of six or more levels. Consider under a disability for 1 year from the time of surgery; thereafter, evaluate the residual impairment; OR

   3. 3. 

      FEV (vital capacity) of 50 percent or less of predicted normal values for the individual's measured (actual) height; OR

3. C. 

   Kyphosis or lordosis measuring 90 degrees or greater.

    

101.08 Chronic Osteomyelitis

With persistence or recurrence of inflammatory signs or drainage for at least six months despite prescribed therapy, and consistent radiographic findings.

 

102.00 Special Senses and Speech

A. Visual Impairments in Children

Impairment of central visual acuity should be determined with use of the standard Snellen test chart. Where this cannot be used, as in very young children, a complete description should be provided of the findings using other appropriate methods of examination, including a description of the techniques used for determining the central visual acuity for distance.

The accommodation reflex is generally not present in children under 6 months of age. In premature infants, it may not be present until six months plus the number of months the child is premature. Therefore, absence of accommodative reflex will be considered as indicating a visual impairment only in children above this age (six months).

Documentation of an opthalmologic disorder must include a description of the ocular pathology.

B. Hearing Impairments in Children

The criteria for hearing impairments in children take into account that a lesser impairment in hearing which occurs at an early age may result in a severe speech and language disorder.

Improvement by a hearing aid, as predicted by the testing procedure, must be demonstrated to be feasible in that child, since younger children may be unable to use a hearing aid effectively.

The type of audiometric testing performed must be described and a copy of the results must be included. The pure tone air conduction hearing levels in 102.08 are based on American National Standard Institute Specifications for Audiometers, S 3.6 - 1969 (ANSI - 1969). The report should indicate the specifications used to calibrate the audiometer.

The finding of a severe impairment will be based on the average hearing levels at 500, 1000, 2000, and 3000 Hertz (Hz) in the better ear, and on speech discrimination, as specified in 102.08.

 

102.01 Category of Impairments, Special Sense Organs

 

102.02 Impairment of Central Visual Acuity

1. A. 

   Remaining vision in the better eye after best correction is 20/200 or less.

2. B. 

   For children below 3 years of age at time of adjudication:

   1. 1. 

      Absence of accommodative reflex (see 102.00A for exclusion of children under six months of age); OR

   2. 2. 

      Retrolental fibroplasia with macular scarring or neovascularization; OR

   3. 3. 

      Bilateral congenital cataracts with visualization of retinal red reflex only or when associated with other ocular pathology.

       

102.08 Hearing Impairments

1. A. 

   For children below 5 years of age at time of adjudication, inability to hear air conduction thresholds at an average of 40 decibels (db) hearing level or greater in the better ear.

2. B. 

   For children 5 years of age and above at time of adjudication:

   1. 1. 

      Inability to hear air conduction thresholds at an average of 70 decibels (db) or greater in the better ear; OR

   2. 2. 

      Speech discrimination scores at 40 percent or less in the better ear; OR

   3. 3. 

      Inability to hear air conduction thresholds at an average of 40 decibels (db) or greater in the better ear, and a speech and language disorder which significantly affects the clarity and content of the speech and is attributable to the hearing impairment.

       

103.00 Respiratory System

A. Documentation of Pulmonary Insufficiency

The reports of spirometric studies for evaluation under Table I must be expressed in liters. The reported FEV₁ should represent the largest of at least three satisfactory attempts, and should be within 10 percent of another FEV₁ . The appropriately labeled spirometric tracing of three FEV maneuvers must be submitted with the report, showing distance per second on the abscissa and distance per liter on the ordinate. The unit distance for volume on the tracing should be at least 15 mm. per liter and the paper speed at least 20 mm. per second. The height of the individual without shoes must be recorded.

The ventilatory function studies should not be performed during or soon after an acute episode or exacerbation of a respiratory illness. In the presence of acute bronchospasm, or where the FEV₁ is less than that stated in Table 1, the studies should be repeated after the administration of a nebulized bronchodilator. If a bronchodilator was not used in such instances, the reason should be stated in the report.

A statement should be made as to the child's ability to understand directions and to cooperate in performance of the test, and should include an evaluation of the child's effort. Where tests cannot be performed or completed, the reason (such as a child's young age) should be stated in the report.

B. Cystic Fibrosis

This section discusses only the pulmonary manifestations of cystic fibrosis. Other manifestations, complications, or associated diseases must be evaluated under the appropriate section.

The diagnosis of cystic fibrosis will be based upon appropriate history, physical examination, and pertinent laboratory findings. Confirmation based upon elevated concentration of sodium or chloride in the sweat should be included, with indication of the technique used for collection and analysis.

 

103.01 Category of Impairments, Respiratory

 

103.03 Bronchial Asthma

With evidence of progression of the disease despite therapy and documented by ONE of the following:

1. A. 

   Recent, recurrent intense asthmatic attacks requiring parenteral medication; OR

2. B. 

   Persistent prolonged expiration with wheezing between acute attacks and radiographic findings of peribronchial disease.

    

103.13 Pulmonary Manifestations of Cystic Fibrosis. With:

1. A. 

   FEV₁ equal to or less than the values specified in Table I (see 103.00A for requirements of ventilatory function testing); OR

2. B. 

   For children where ventilatory function testing cannot be performed:

   1. 1. 

      History of dyspnea on mild exertion or chronic frequent productive cough; AND

   2. 2. 

      Persistent or recurrent abnormal breath sounds, bilateral rales or rhonchi; AND

   3. 3. 

      Radiographic findings of extensive disease with hyperaeration and bilateral peribronchial infiltration.

104.00 Cardiovascular System

A. General

Evaluation should be based upon history, physical findings, and appropriate laboratory data. Reported abnormalities should be consistent with the pathologic diagnosis. The actual electrocardiographic tracing, or an adequate marked photocopy, must be included. Reports of other pertinent studies necessary to substantiate the diagnosis or describe the severity of the impairment also must be included.

B. Evaluation

Evaluation of cardiovascular impairments in children requires two steps:

1. 1. 

   The delineation of a specific cardiovascular disturbance, either congenital or acquired. This may include arterial or venous disease, rhythm disturbance, or disease involving the valves, septa, myocardium, or pericardium; and

2. 2. 

   Documentation of the severity of the impairment, with medically determinable and consistent cardiovascular signs, symptoms, and laboratory data. In cases where impairment characteristics are questionably secondary to the cardiovascular disturbance, additional documentation of the severity of the impairment (e.g., catheterization data, if performed) will be necessary.

C. Chest Roentgenogram

A 6 ft. PA film will be considered indicative of cardiomegaly if:

1. 1. 

   The cardiothoracic ratio is over 60 percent at age one year or less, or 55 percent at more than one year of age; OR

2. 2. 

   The cardiac size is increased over 15 percent from any prior chest roentgenograms; OR

3. 3. 

   Specific chamber or vessel enlargement is documented in accordance with established criteria.

D. Tables I, II, and III

The tables below are designed for case adjudication and not for diagnostic purposes. The adult criteria may be useful for older children and should be used when applicable.

E. Rheumatic Fever

As used in this section, assumes diagnoses made according to the revised Jones criteria.

 

104.01 Category of Impairments, Cardiovascular

 

104.02 Chronic Congestive Failure

With TWO or MORE of the following signs:

1. A. 

   Tachycardia (see Table I).

2. B. 

   Tachypnea (see Table II).

3. C. 

   Cardiomegaly on chest roentgenogram (see C. above).

4. D. 

   Hepatomegaly (more than 2 cm. below the right costal margin in the right midclavicular line).

5. E. 

   Evidence of pulmonary edema, such as rales or orthopnea.

6. F. 

   Dependent edema.

7. G. 

   Exercise intolerance manifested as labored respiration on mild exertion (e.g., in an infant, feeding).

104.03 Hypertensive Cardiovascular Disease

With persistently elevated blood pressure for age (see Table III) and ONE of the following:

1. A. 

   Impaired renal function as described under the criteria in 106.02; OR

2. B. 

   Cerebrovascular damage as described under the criteria in 111.06; OR

3. C. 

   Congestive heart failure as described under the criteria in 104.02.

104.04 Cyanotic Congenital Heart Disease

With ONE of the following:

1. A. 

   Surgery is limited to palliative measure; OR

2. B. 

   Characteristic squatting, hemoptysis, syncope, or hypercyanotic spells; OR

3. C. 

   Chronic hematocrit of 55 percent or greater or arterial O2 saturation of less than 90 percent at rest, or arterial oxygen tension of less than 60 Torr at rest.

    

104.05 Cardiac Arrhythmia

Such as persistent or recurrent heart block or A-V dissociation (with or without therapy) and ONE of the following:

1. A. 

   Cardiac syncope; OR

2. B. 

   Congestive heart failure as described under the criteria in 104.02 of this section; OR

3. C. 

   Exercise intolerance with labored respirations on mild exertion (e.g., in infants, feeding).

    

104.07 Cardiac Syncope

With at least one documented syncopal episode characteristic of specific cardiac disease (e.g., aortic stenosis).

 

104.08 Recurrent Hemoptysis

Associated with either pulmonary hypertension or extensive bronchial collaterals due to documented chronic cardiovascular disease.

 

104.09 Chronic Rheumatic Fever or Rheumatic Heart Disease

With:

1. A. 

   Persistence of rheumatic fever activity for six months or more, with significant murmur(s), cardiomegaly (see 104.00C), and other abnormal laboratory findings (such as elevated sedimentation rate or electrocardiographic findings); OR

2. B. 

   Congestive heart failure as described under the criteria in 104.02 of this section.

    

105.00 Digestive System

A. Disorders of the Digestive System

Disorders of the digestive system which result in disability usually do so because of interference with nutrition and growth, multiple recurrent inflammatory lesions, or other complications of the disease. Such lesions or complications usually respond to treatment. To constitute a listed impairment, these must be shown to have persisted or be expected to persist despite prescribed therapy for a continuous period of at least 12 months.

B. Documentation

Documentation of gastrointestinal impairments should include pertinent operative findings, radiographic studies, endoscopy, and biopsy reports. Where a liver biopsy has been performed in chronic liver disease, documentation should include the report of the biopsy.

C. Growth Retardation and Malnutrition

When the primary disorder of the digestive tract has been documented, evaluate resultant malnutrition under the criteria described in 105.08. Evaluate resultant growth impairment under the criteria described in 100.03. Intestinal disorders, including surgical diversions and potentially correctable congenital lesions, do not represent a severe impairment if the individual is able to maintain adequate nutrition, growth, and development.

D. Multiple Congenital Anomalies

See related criteria, and consider as a combination of impairments.

 

105.01 Category of Impairments, Digestive

 

105.03 Esophageal Obstruction

Caused by atresia, stricture, or stenosis. With malnutrition as described under the criteria in 105.08.

 

105.05 Chronic Liver Disease

With ONE of the following:

1. A. 

   Inoperable biliary atresia demonstrated by x-ray or surgery; OR

2. B. 

   Intractable ascites not attributable to other causes, with serum albumin of 3.0 gm./100 ml. or less; OR

3. C. 

   Esophageal varices (demonstrated by angiography, barium swallow, or endoscopy or by prior performance of a specific shunt or plication procedure); OR

4. D. 

   Hepatic coma, documented by findings from hospital records; OR

5. E. 

   Hepatic encephalopathy. Evaluate under the criteria in 112.02; OR

6. F. 

   Chronic active inflammation or necrosis documented by SGOT persistently more than 100 units or serum bilirubin of 2.5 mg. percent or greater.

    

105.07 Chronic Inflammatory Bowel Disease

Such as ulcerative colitis, regional enteritis, as documented in 105.00. With ONE of the following:

1. A. 

   Intestinal manifestations or complications, such as obstruction, abscess, or fistula formation which has lasted or is expected to last 12 months; OR

2. B. 

   Malnutrition as described under the criteria in 105.08; OR

3. C. 

   Growth impairment as described under the criteria in 100.03.

    

105.08 Malnutrition

Due to demonstrable gastrointestinal disease causing either a fall of 15 percentiles of weight which persists or the persistence of weight which is less than the third percentile (on standard growth charts) and ONE of the following:

1. A. 

   Stool fat excretion per 24 hours:

   1. 1. 

      More than 15 percent in infants less than 6 months.

   2. 2. 

      More than 10 percent in infants 6-18 months.

   3. 3. 

      More than 6 percent in children more than 18 months; OR

2. B. 

   Persistent hematocrit of 30 percent or less despite prescribed therapy; OR

3. C. 

   Serum carotene of 40 mcg./100 ml. or less; OR

4. D. 

   Serum albumin of 3.0 gm./100 ml. or less.

    

106.00 Genito-Urinary System

A. General

Determination of the presence of chronic renal disease will be based upon the following factors:

1. 1. 

   History, physical examination, and laboratory evidence of renal disease.

2. 2. 

   Indications of its progressive nature or laboratory evidence of deterioration of renal function.

B. Renal Transplant

The amount of function restored and the time required to effect improvement depend upon various factors including adequacy of post-transplant renal function, incidence of renal infection, occurrence of rejection crisis, presence of systemic complications (anemia, neuropathy, etc.) and side effects of corticosteriod or immunosuppressive agents. A period of at least 12 months is required for the individual to reach a point of stable medical improvement.

C. Evaluation of Associated Disorders

Evaluate associated disorders and complications according to the appropriate body system listing.

 

106.01 Category of Impairments, Genito-Urinary

 

106.02 Chronic Renal Disease

With:

1. A. 

   BUN of 30 mg./100 ml. or greater; OR

2. B. 

   Serum creatinine of 3.0 mg./100 ml. or greater; OR

3. C. 

   Creatinine clearance equal to or less than 42 ml./min./1.73 m2; OR

4. D. 

   Chronic renal dialysis program for irreversible renal failure; OR

5. E. 

   Renal transplant. Consider under a disability for 12 months following surgery; thereafter, evaluate the residual impairment (see 106.00B).

    

106.06 Nephrotic Syndrome

With edema not controlled by prescribed therapy. And:

1. A. 

   Serum albumin less than 2 gm./100 ml.; OR

2. B. 

   Proteinuria more than 2.5 gm./1.73 m² /day.

    

107.00 Hemic and Lymphatic System

A. Sickle Cell Disease

Sickle cell disease refers to a chronic hemolytic anemia associated with sickle cell hemoglobin, either homozygous or in combination with thalassemia or with another abnormal hemoglobin (such as C or F).

Appropriate hematologic evidence for sickle cell disease, such as hemoglobin electrophoresis must be included. Vaso-occlusive, hemolytic, or aplastic episodes should be documented by description of severity, frequency, and duration.

Disability due to sickle cell disease may be solely the result of a severe, persistent anemia or may be due to the combination of chronic progressive or episodic manifestations in the presence of a less severe anemia.

Major visceral episodes causing disability include meningitis, osteomyelitis, pulmonary infections or infarctions, cerebrovascular accidents, congestive heart failure, genito-urinary involvement, etc.

B. Coagulation Defects

Chronic inherited coagulation disorders must be documented by appropriate laboratory evidence such as abnormal thromboplastin generation, coagulation time, or factor assay.

C. Acute Leukemia

Initial diagnosis of acute leukemia must be based upon definitive bone marrow pathologic evidence. Recurrent disease may be documented by peripheral blood, bone marrow, or cerebrospinal fluid examination. The pathology report must be included.

The designated duration of disability implicit in the finding of a listed impairment is contained in 107.11. Following the designated time period, a documented diagnosis itself is no longer sufficient to establish a severe impairment. The severity of any remaining impairment must be evaluated on the basis of the medical evidence.

 

107.01 Category of Impairments, Hemic and Lymphatic

 

107.03 Hemolytic Anemia

Due to any cause. Manifested by persistence of hematocrit of 26 percent or less despite prescribed therapy, and reticulocyte count of 4 percent or greater.

 

107.05 Sickle Cell Disease

With:

1. A. 

   Recent, recurrent severe vaso-occlusive crises (musculoskeletal, vertebral, abdominal); OR

2. B. 

   A major visceral complication in the 12 months prior to application; OR

3. C. 

   A hyperhemolytic or aplastic crisis within 12 months prior to application; OR

4. D. 

   Chronic, severe anemia with persistence of hematocrit of 26 percent or less; OR

5. E. 

   Congestive heart failure, cerebrovascular damage, or emotional disorder as described under the criteria in 104.02, 111.00ff, or 112.00ff.

    

107.06 Chronic Idiopathic Thrombocytopenic Purpura of Childhood

With purpura and thrombocytopenia of 40,000 platelets/cu.mm. or less despite prescribed therapy or recurrent upon withdrawal of treatment.

 

107.08 Inherited Coagulation Disorder

With:

1. A. 

   Repeated spontaneous or inappropriate bleeding; OR

2. B. 

   Hemarthrosis with joint deformity.

    

107.11 Acute Leukemia

Consider under a disability:

1. A. 

   For 2 1/2 years from the time of initial diagnosis; OR

2. B. 

   For 2 1/2 years from the time of recurrence of active disease.

    

109.00 Endocrine System

A. Cause of Disability

Disability is caused by a disturbance in the regulation of the secretion or metabolism of one or more hormones which are not adequately controlled by therapy. Such disturbances or abnormalities usually respond to treatment. To constitute a listed impairment these must be shown to have persisted or be expected to persist despite prescribed therapy for a continuous period of at least 12 months.

B. Growth

Normal growth is usually a sensitive indicator of health as well as of adequate therapy in children. Impairment of growth may be disabling in itself or may be an indicator of a severe disorder involving the endocrine system or other body systems. 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.

C. Documentation

Description of characteristic history, physical findings, and diagnostic laboratory data must be included. Results of laboratory tests will be considered abnormal if outside the normal range or greater than two standard deviations from the mean of the testing laboratory. Reports in the file should contain the information provided by the testing laboratory as to their normal values for that test.

D. Hyperfunction of the Adrenal Cortex

Evidence of growth retardation must be documented as described in 100.00. Elevated blood or urinary free cortisol levels are not acceptable in lieu of urinary 17-hydroxycorticosteroid excretion for the diagnosis of adrenal cortical hyperfunction.

E. Adrenal Cortical Insufficiency

Documentation must include persistent low plasma cortisol or low urinary 17-hydroxycorticosteroids or 17-ketogenic steroids and evidence of unresponsiveness to ACTH stimulation.

 

109.01 Category of Impairments, Endocrine

 

109.02 Thyroid Disorders

1. A. 

   Hyperthyroidism (as documented in 109.00C above). With clinical manifestations despite prescribed therapy, and ONE of the following:

   1. 1. 

      Elevated serum thyroxine (T4) and either elevated free T4 or resin T3 uptake; OR

   2. 2. 

      Elevated thyroid uptake of radioiodine; OR

   3. 3. 

      Elevated serum triiodothyronine (T3).

2. B. 

   Hypothyroidism. With ONE of the following, despite prescribed therapy:

   1. 1. 

      IQ of 69 or less; OR

   2. 2. 

      Growth impairment as described under the criteria in 100.02A and B; OR

   3. 3. 

      Precocious puberty.

       

109.03 Hyperparathyroidism

As documented in 109.00C with:

1. A. 

   Repeated elevated total or ionized serum calcium; OR

2. B. 

   Elevated serum parathyroid hormone.

    

109.04 Hypoparathyroidism or Pseudohypoparathyroidism

With:

1. A. 

   Severe recurrent tetany or convulsions which are unresponsive to prescribed therapy; OR

2. B. 

   Growth retardation as described under the criteria in 100.02A and B.

    

109.05 Diabetes Insipidus

Documented by pathologic hypertonic saline or water deprivation test. And ONE of the following:

1. A. 

   Intracranial space-occupying lesion, before or after surgery; OR

2. B. 

   Unresponsiveness to Pitressin; OR

3. C. 

   Growth retardation as described under the criteria in 100.02A and B; OR

4. D. 

   Unresponsive hypothalmic thirst center, with chronic or recurrent hypernatremia; OR

5. E. 

   Decreased visual fields attributable to a pituitary lesion.

    

109.06 Hyperfunction of the Adrenal Cortex

Primary or secondary with:

1. A. 

   Elevated urinary 17-hydroxycorticosteroids (or 17-ketogenic steroids) as documented in 109.00C and above; AND

2. B. 

   Unresponsiveness to low-dose dexamethasone suppression.

    

109.07 Adrenal Cortical Insufficiency

As documented in 109.00C and E above with recent, recurrent episodes of circulatory collapse.

 

109.08 Juvenile Diabetes Mellitus

As documented in 109.00C requiring parenteral insulin. And ONE of the following, despite prescribed therapy:

1. A. 

   Recent, recurrent hospitalizations with acidosis; OR

2. B. 

   Recent, recurrent episodes of hypoglycemia; OR

3. C. 

   Growth retardation as described under the criteria in 100.02A or B; OR

4. D. 

   Impaired renal function as described under the criteria in 106.00ff.

    

109.09 Iatrogenic Hypercorticoid State

With chronic glucocorticoid therapy resulting in ONE of the following:

1. A. 

   Osteoporosis; OR

2. B. 

   Growth retardation as described under the criteria in 100.02A or B; OR

3. C. 

   Diabetes mellitus as described under the criteria in 109.08 above OR

4. D. 

   Myopathy as described under the criteria in 111.06; OR

5. E. 

   Emotional disorder as described under the criteria in 112.00ff.

    

109.10 Pituitary Dwarfism

With documented growth hormone deficiency, and growth impairment as described under the criteria in 100.02B.

 

109.11 Adrenogenital Syndrome

With:

1. A. 

   Recent, recurrent salt-losing episodes despite prescribed therapy; OR

2. B. 

   Inadequate replacement therapy manifested by accelerated bone age and virilization; OR

3. C. 

   Growth impairment as described under the criteria in 100.02A or B.

    

109.12 Hypoglycemia

As documented in 109.00C with recent, recurrent hypoglycemic episodes producing convulsion or coma.

 

109.13 Gonadal Dysgenesis (Turner's Syndrome)

Chromosomally proven. Evaluate the resulting impairment under the criteria for the appropriate body system.

 

110.00 Multiple Body Systems

A. Catastrophic Congenital Abnormalities or Disease

This section refers only to very serious congenital disorders, diagnosed in the newborn or infant child.

B. Immune Deficiency Diseases

Documentation of immune deficiency disease must be submitted, and may include quantitative immunoglobulins, skin tests for delayed hypersensitivity, lymphocyte stimulative tests, and measurements of cellular immunity mediators.

 

110.01 Category of Impairments, Multiple Body Systems

 

110.08 Catastrophic Congenital Abnormalities or Disease

With:

1. A. 

   A positive diagnosis (such as anencephaly, trisomy D or E, cyclopia, etc.), generally regarded as being incompatible with extra-uterine life; OR

2. B. 

   A positive diagnosis (such as cri du chat, Tay-Sachs Disease) wherein attainment of the growth and development level of 2 years is not expected to occur.

    

110.09 Immune Deficiency Disease

1. A. 

   Hypogammaglobulinemia or dysgammaglobulinemia. With:

   1. 1. 

      Recent, recurrent severe infections; OR

   2. 2. 

      A complication such as growth retardation, chronic lung disease, collagen disorder, or tumors.

2. B. 

   Thymic dysplastic syndromes (such as Swiss, diGeorge).

    

111.00 Neurological

A. Seizure Disorder

Seizure disorder must be substantiated by at least one detailed description of a typical seizure. Report of recent documentation should include an electroencephalogram and neurological examination. Sleep EEG is preferable, especially with temporal lobe seizures. Frequency of attacks and any associated phenomena should also be substantiated.

Young children may have convulsions in association with febrile illnesses. Proper use of 111.02 and 111.03 requires that a seizure disorder be established. Although this does not exclude consideration of seizures occurring during febrile illnesses, it does require documentation of seizures during nonfebrile periods.

There is an expected delay in control of seizures when treatment is started, particularly when changes in the treatment regimen are necessary. Therefore, a seizure disorder should not be considered to meet the requirements of 111.02 and 111.03 unless it is shown that seizures have persisted more than three months after prescribed therapy began.

B. Minor Motor Seizures

Classical petit mal seizures must be documented by characteristic EEG pattern, plus information as to age at onset and frequency of clinical seizures. Myoclonic seizures, whether of the typical infantile or Lennox-Gastaut variety after infancy, must also be documented by the characteristic EEG pattern plus information as to age at onset and frequency of seizures.

C. Motor Dysfunction

As described in 111.06, motor dysfunction may be due to any neurological disorder. It may be due to static or progressive conditions involving any area of the nervous system and producing any type of neurological impairment. This may include weakness, spasticity, lack of coordination, ataxia, tremor, athetosis, or sensory loss. Documentation of motor dysfunction must include neurologic findings and description of type of neurologic abnormality (e.g., spasticity, weakness), as well as a description of the child's functional impairment (i.e., what the child is unable to do because of the abnormality). Where a diagnosis has been made, evidence should be included for substantiation of the diagnosis (e.g., blood chemistries and muscle biopsy reports), wherever applicable.

D. Impairment of Communication

The documentation should include a description of a recent comprehensive evaluation, including all areas of affective and effective communication, performed by a qualified professional.

 

111.01 Category of Impairments, Neurological

 

111.02 Major Motor Seizure Disorder

A. Major Motor Seizures

In a child with an established seizure disorder, the occurrence of more than one major motor seizure per month despite at least three months of prescribed treatment. With:

1. 1. 

   Daytime episodes (loss of consciousness and convulsive seizures); OR

2. 2. 

   Nocturnal episodes manifesting residuals which interfere with activity during the day.

B. Major Motor Seizures

In a child with an established seizure disorder, the occurrence of at least one major motor seizure in the year prior to application despite at least three months of prescribed treatment. And ONE of the following:

1. 1. 

   IQ of 69 or less; OR

2. 2. 

   Significant interference with communication due to speech, hearing, or visual defect; OR

3. 3. 

   Significant emotional disorder; OR

4. 4. 

   Where significant adverse effects of medication interfere with major daily activities.

    

111.03 Minor Motor Seizure Disorder

In a child with an established seizure disorder, the occurrence of more than one minor motor seizure per week, with alteration of awareness or loss of consciousness, despite at least three months of prescribed treatment.

 

111.05 Brain Tumors

1. A. 

   Malignant gliomas (astrocytoma--Grades III and IV, glioblastoma multiforme), medulloblastoma, ependymoblastoma, primary sarcoma, or brain stem gliomas; OR

2. B. 

   Evaulate other brain tumors under the criteria for the resulting neurological impairment.

    

111.06 Motor Dysfunction

Due to any neurological disorder. Persistent disorganization or deficit of motor function for age involving two extremities, which (despite prescribed therapy) interferes with age-appropriate major daily activities and results in disruption of:

1. A. 

   Fine and gross movements; OR

2. B. 

   Gait and station.

    

111.07 Cerebral Palsy.

With:

1. A. 

   Motor dysfunction meeting the requirements of 111.06 or 101.03; OR

2. B. 

   Less severe motor dysfunction (but more than slight) and one of the following:

   1. 1. 

      IQ or 69 or less; OR

   2. 2. 

      Seizure disorder, with at least one major motor seizure in the year prior to application; OR

   3. 3. 

      Significant interference with communication due to speech, hearing, or visual defect; OR

   4. 4. 

      Significant emotional disorder.

       

111.08 Meningomyelocele (And Related Disorders)

With one of the following despite prescribed treatment:

1. A. 

   Motor dysfunction meeting the requirements of 101.03 or 111.06; OR

2. B. 

   Less severe motor dysfunction (but more than slight), and:

   1. 1. 

      Urinary or fecal incontinence when inappropriate for age; OR

   2. 2. 

      IQ of 69 or less; OR

3. C. 

   Four extremity involvement; OR

4. D. 

   Noncompensated hydrocephalus producing interference with mental or motor developmental progression.

    

111.09 Communication Impairment

Associated with documented neurological disorder, and one of the following:

1. A. 

   Documented speech deficit which significantly affects the clarity and content of the speech; OR

2. B. 

   Documented comprehension deficit resulting in ineffective verbal communication for age; OR

3. C. 

   Impairment of hearing as described under the criteria in 102.08.

    

112.00 Mental and Emotional Disorders

A. Introduction

This section is intended primarily to describe mental and emotional disorders of young children. The criteria describing medically determinable impairments in adults should be used where they clearly appear to be more appropriate.

B. Mental Retardation

  1. GENERAL

As with any other impairment, the necessary evidence consists of symptoms, signs, and laboratory findings which provide medically demonstrable evidence of impairment severity. Standardized intelligence test results are essential to the adjudication of all cases of mental retardation that are not clearly covered under the provisions of 112.05A. Developmental milestone criteria may be the sole basis for adjudication only in cases where the child's young age and/or condition preclude formal standardized testing by a psychologist or psychiatrist experienced in testing children.

  2. MEASURES OF INTELLECTUAL FUNCTIONING

Standardized intelligence tests, such as the Wechsler Preschool and Primary Scale of Intelligence (WPPSI), the Wechsler Intelligence Scale for Children (WISC), the Revised Stanford-Binet Scale, and the McCarthey Scales of Children's Abilities, should be used wherever possible. Key data such as subtest scores should also be included in the report. Tests should be administered by a qualified and experienced psychologist or psychiatrist, and any discrepancies between formal test results and the child's customary behavior and daily activities should be duly noted and resolved.

  3. DEVELOPMENTAL MILESTONE CRITERIA

In the event that a child's young age and/or condition preclude formal testing by a psychologist or psychiatrist experienced in testing children, a comprehensive evaluation covering the full range of developmental activities should be performed. This should consist of a detailed account of the child's daily activities together with direct observations by a professional person; the latter should include indices or manifestations of social, intellectual, adaptive, verbal, motor (posture, locomotion, manipulation), language, emotional, and self-care development for age. The above should then be related by the evaluating or treating physician to establish developmental norms of the kind found in any widely used standard pediatrics text.

C. Profound Combined Mental-Neurological-
   Musculoskeletal Impairments

There are children with profound and irreversible brain damage resulting in total incapacitation. Such children may meet criteria in either neurological, musculoskeletal, and/or mental sections; they should be adjudicated under the criteria most completely substantiated by the medical evidence submitted. Frequently, the most appropriate criteria will be found under the mental impairment section.

 

112.01 Category of Impairments, Mental and Emotional

 

112.02 Chronic Brain Syndrome

With arrest of developmental progression for at least 6 months or loss of previously acquired abilities.

 

112.03 Psychosis of Infancy and Childhood

Documented by psychiatric evaluation and supported, if necessary, by the results of appropriate standardized psychological tests and manifested by marked restriction in the performance of daily age-appropriate activities; constriction of age-appropriate interests; deficiency of age-appropriate self-care skills; and impaired ability to relate to others; together with persistence of one (or more) of the following:

1. A. 

   Significant withdrawal or detachment; OR

2. B. 

   Impaired sense of reality; OR

3. C. 

   Bizarre behavior patterns; OR

4. D. 

   Strong need for maintenance of sameness, with intense anxiety, fear, or anger when change is introduced; OR

5. E. 

   Panic at threat of separation from parent.

    

112.04 Functional Nonpsychotic Disorders

Documented by psychiatric evaluation and supported, if necessary, by the results of appropriate standardized psychological tests and manifested by marked restriction in the performance of daily age-appropriate activites; constriction of age-appropriate interests; deficiency of age-appropriate self-care skills; and impaired ability to relate to others; together with persistence of one (or more) of the following:

1. A. 

   Psychophysiological disorder (e.g., diarrhea, asthma); OR

2. B. 

   Anxiety; OR

3. C. 

   Depression; OR

4. D. 

   Phobic, obsessive, or compulsive behavior; OR

5. E. 

   Hypochondriasis; OR

6. F. 

   Hysteria; OR

7. G. 

   Asocial or antisocial behavior.

    

112.05 Mental Retardation

1. A. 

   Achievement of only those developmental milestones generally acquired by children no more than one-half the child's chronological age; OR

2. B. 

   IQ of 59 or less; OR

3. C. 

   IQ of 60-69, inclusive, and a physical or other mental impairment imposing additional and significant restriction of function or developmental progression.

    

113.00 Neoplastic Diseases, Malignant

A. Introduction

Determination of disability in the growing and developing child with a malignant neoplastic disease is based upon the combined effects of:

1. 1. 

   The pathophysiology, histology, and natural history of the tumor; AND

2. 2. 

   The effects of the currently employed aggressive multimodal therapeutic regimens.

Combinations of surgery, radiation, and chemotherapy or prolonged therapeutic schedules impart significant additional morbidity to the child during the period of greatest risk from the tumor itself. This period of highest risk and greatest therapeutically-induced morbidity defines the limits of disability for most of childhood neoplastic disease.

B. Documentation

The diagnosis of neoplasm 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, along with all pertinent laboratory and X-ray reports. The evidence should also include a recent report directed especially at describing whether there is evidence of local or regional recurrence, soft part or skeletal metastases, and significant post-therapeutic residuals.

C. Malignant Solid Tumors

As listed under 113.03, include the histiocytosis syndromes except for solitary eosinophilic granuloma. Thus, 113.03 should not be used for evaluating brain tumors (see 111.05) or thyroid tumors, which must be evaluated on the basis of whether they are controlled by prescribed therapy.

D. Duration

Duration of disability from malignant neoplastic tumors is included in 113.02 and 113.03. Following the time periods designated in these sections, a documented diagnosis itself is no longer sufficient to establish a severe impairment. The severity of a remaining impairment must be evaluated on the basis of the medical evidence.

 

113.01 Category of Impairments, Neoplastic Diseases, Malignant

 

113.02 Lymphoreticular Malignant Neoplasms

Consider under a disability:

1. A. 

   For 2 1/2 years from the time of initial diagnosis, OR

2. B. 

   For 2 1/2 years from the time of recurrence of active disease.

    

113.03 Malignant Solid Tumors

Consider under a disability:

1. A. 

   For 2 years from the time of initial diagnosis; OR

2. B. 

   For 2 years from the time of recurrence of active disease.

    

113.04 Neuroblastoma.

With ONE of the following:

1. A. 

   Extension across the midline; OR

2. B. 

   Distant metastases; OR

3. C. 

   Recurrence; OR

4. D. 

   Onset at age 1 year or older.

    

113.05 Retinoblastoma

With ONE of the following:

1. A. 

   Bilateral involvement; OR

2. B. 

   Metastases; OR

3. C. 

   Extension beyond the orbit; OR

4. D. 

   Recurrence.