Identification Number:
EM-21027
Intended Audience:All RCs/ARCs/ADs/FOs/TSCs/PSCs/OCO
/OHO/OARO/DDSs
Originating Office:ORDP ODP
Title:Additional Guidance for Evaluating Evidence in Cases Involving the Musculoskeletal Disorders Listings
Type:EM - Emergency Messages
Program:Disability
Link To Reference:See References at the end of this EM.
 
Retention Date: October 01, 2021

A. Purpose

This emergency message (EM) provides instructions for disability adjudicators on evaluating evidence in cases involving the musculoskeletal disorders listings beginning April 2, 2021. Specifically it provides additional guidance for evaluating the “documented medical need” for a wheeled and seated mobility device (WSMD) (see 1.00C6 and 101.00C6) and applying the “close proximity of time” standard with respect to the imaging requirement (see 1.00C7 and 101.00C7) beginning April 2, 2021.

Regional Offices must ensure that all disability adjudicators, including medical consultants, administrative law judges, and senior attorney adjudicators, receive this message.

B. Background

On December 3, 2020, we published new listings for evaluating musculoskeletal disorders that are effective on April 2, 2021. See 85 FR 78164. In addition to other changes, in response to public comments on the notice of proposed rulemaking (NPRM), we included criteria in the functional criteria for evaluating the documented medical need for WSMDs. The new listings also contain uniform and specific severity criteria for evaluating the effects of a musculoskeletal disorder on a person’s functioning and resolve the inconsistent policy application created by Acquiescence Ruling (AR) 15-1(4), Radford v. Colvin, 734 F.3d 288 (4th Cir. 2013).
We are rescinding AR 15-1(4) on the effective date of these new listings.

Since publishing these new listings, we have received inquiries related to how we evaluate the documented medical need for a WSMD, particularly one-handed WSMDs, and the new functional criteria. We have also received questions about the “close proximity of time” standard with respect to the imaging requirement. This EM will promote consistent application of the new musculoskeletal disorders listings with regard to these issues.

C. Considering the most restrictive assistive device for which the claimant has a documented medical need when evaluating the functional criteria

Beginning April 2, 2021, consider the most restrictive assistive device for which the claimant has a documented medical need when evaluating the functional criteria. The “most restrictive device” is the device that involves the greatest limitation on the claimant’s use of the upper extremities, which is the focus of the functional criteria.

We consider assistive devices under both the first and second functional criteria in the musculoskeletal listings. These criteria require:
    1. A documented medical need for a walker, bilateral canes, or bilateral crutches or a WSMD involving the use of both hands, or
    2. An inability to use one upper extremity to independently initiate, sustain, and complete work-related activities (or, for a child, to perform age-appropriate activities) involving fine and gross movements, and a documented medical need for a one-handed, hand-held assistive device that requires the use of the other upper extremity or a WSMD involving the use of one hand

The phrase “documented medical need” means that there is evidence from a medical source that supports the medical need for an assistive device for a continuous period of at least 12 months. This evidence must describe any limitation(s) in upper or lower extremity functioning and the circumstances for which the claimant needs to use the assistive device. We do not require that the claimant have a specific prescription for the assistive device. See 1.00C6a and 101.00C6a.
      Example: A claimant alternates between a walker and a motorized (that is, one-handed) WSMD, and has a documented medical need for both devices. Consider the two-handed assistive device criterion because the claimant has a documented medical need for a walker, and the walker is the most restrictive assistive device for which the claimant has a documented medical need.

D. Evaluating “documented medical need” for claimants who use a WSMD

The functional criteria are satisfied if the medical evidence shows that a claimant uses a WSMD that involves the use of two hands, such as a standard manual wheelchair, for which he or she has a documented need lasting 12 consecutive months due to a musculoskeletal impairment.

Beginning April 2, 2021, if the claimant uses a WSMD that involves the use of one hand, such as a powered wheelchair or scooter, or if there is not enough evidence to determine what type of WSMD the claimant uses, consider whether the claimant may have a “documented medical need” for a two-handed assistive device that would satisfy the first functional criterion as noted in C.1.above, regardless of whether they actually use such a device. If a claimant uses a one-handed WSMD for which there is a documented medical need, but needs the support of both hands to complete the activities necessary to function in a typical work environment, consider that the claimant has a documented medical need for a two-handed assistive device and satisfies the first functional criterion as noted in C.1 above.
      Example: A claimant who cannot bear weight on his or her lower extremities due to a musculoskeletal disorder would need the support of two hands to complete activities necessary to function in a typical work environment, such as transferring from his or her WSMD. Use the first functional criterion to evaluate this case.
Beginning April 2, 2021, when evaluating whether a claimant has a documented medical need for an assistive device that satisfies the functional criteria noted in C.1 above, consider evidence in the medical record including, but not limited to:
    · Documentation of the use and description of any assistive device(s);
    · Inability to bear weight on the lower extremities;
    · Instability;
    · Inability to rise from a seated position without assistance or the use of both arms;
    · Significant weakness in the legs; or
    · Amputation of the lower extremities at or above the ankle with inability to use a prosthesis.

NOTE: Even if the functional criteria are satisfied, all other criteria must be satisfied in order for the impairment to meet or medically equal the listing.

If the evidence does not support a finding that the claimant’s impairment(s) meets or medically equals the listing, proceed to the next step of the sequential evaluation process. For adults, consider the claimant’s residual functional capacity, including the limited ability to stand and walk and the use of the WSMD. For children seeking Supplemental Security Income (SSI) payments under title XVI, consider whether the impairment(s) functionally equals the listings.

NOTE: The medical-vocational rules for adults and the functional equivalence rules for children seeking SSI have not changed.

E. Determining “close proximity of time” with regard to imaging requirements

Beginning April 2, 2021, to satisfy the requirements of Listings 1.15, 1.16, 1.17, 1.18, 1.20C, 1.20D, 1.22, 1.23, 101.15, 101.16, 101.17, 101.18, 101.20C, 101.20D, 101.22, and 101.23, all required criteria must be present simultaneously, or within a close proximity of time. In evaluating cases involving musculoskeletal disorders with listings that have imaging requirements, and imaging findings are documented in the medical record, determine whether you can “reasonably expect” the findings on imaging to have been present within a close proximity of time of the other required elements. See 1.00C7b and 101.00C7b.

Do not find that a case fails to meet the listing or do not require additional development simply because the imaging was not taken within a “close proximity of time” to the other required listing elements. In most cases, no additional imaging or development is necessary unless there was a potentially corrective surgery or other intervention between the timeframe of the imaging and the other findings.

Use judgment in determining whether you can “reasonably expect” that the findings were present within a close proximity of time of the other elements. Consider factors including, but not limited to:
    · Are the findings consistent with the other evidence? If the signs and symptoms are consistent with what we would expect from the specific findings and there is no other explanation for the signs and symptoms (for example, a recent injury), then you will generally “reasonably expect” that the findings would be present.
    · What kinds of findings were present on imaging? If the findings on imaging are the kind that generally remain static or worsen, you will generally find that you can “reasonably expect” them to continue to be present. If the findings are the kind that can improve over time, you might not “reasonably expect” them to continue to be present, particularly if they are far removed from the date of adjudication.
    · How recent is the imaging? If the findings are the kind that may improve over time or if the imaging is several years old, you might not “reasonably expect” the findings to remain present.
    · What is the longitudinal medical history? If there was surgery or other intervening treatment that could improve the findings that were seen on imaging, you will generally not “reasonably expect” that the findings would remain present.


F. Evaluating WSMDs outside of the musculoskeletal disorders listings
    1. Impairments other than musculoskeletal impairments
      Do not apply the musculoskeletal functional criteria to all cases involving use of a WSMD. Only apply these criteria to cases with a musculoskeletal impairment. Continue to evaluate cases involving other body systems under the listings for the relevant body system (for example, neurological or respiratory disorders).
      Example: Evaluate the need for a WSMD due to a disorder or injury of the skeletal spine that results in damage to, and neurological dysfunction of, the spinal cord and its associated nerves (for example, paraplegia or quadriplegia) under the listings in 11.00 and 111.00.

    2. Impairments that do not meet or medically equal a listing
      Evaluate WSMDs used for impairments that do not meet or medically equal a listing using the current medical-vocational rules for adults or functional equivalence rules for children seeking SSI. These rules have not changed as a result of the changes to the musculoskeletal disorders listings.

G. Continuing disability reviews (CDR)

Use the current CDR rules and the Medical Improvement Review Standard (MIRS) to determine whether disability continues, including whether the impairment continues to meet or medically equal the same listing section used to make the most recent favorable decision, see DI 28005.015 and DI 28015.050.

References
DI 22505.008 Developing Supplemental Evidence
DI 22505.010 Development Issues - Longitudinal Medical Evidence
DI 28005.015 Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process
DI 28015.050 Consideration of Prior Listing
85 FR 78164 Revised Medical Criteria for Evaluating Musculoskeletal Disorders Final Rules

EM-21027 - Additional Guidance for Evaluating Evidence in Cases Involving the Musculoskeletal Disorders Listings - 4/2/2021