Identification Number:
DI 25220 TN 2
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Impairment Severity - Not Severe, Meets and Medical Equals
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 252 – Title XVI Child Claims Based on Disability
Subchapter 20 – Impairment Severity - Not Severe, Meets and Medical Equals
Transmittal No. 2, 11/04/2019

Audience

PSC: DE, DEC;
OCO-OEIO: CR, ERE, FDE, RECONE;
OCO-ODO: DE, DEC, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

Section 832 of the Bipartisan Budget Act (BBA) of 2015 revised the statutory language in section 221(h) of the Social Security Act, effective November 2, 2016.

In conjunction with the BBA, we are issuing clarifying language for the affected instructions. The clarifying instructions provide a cross-reference of the necessary qualifications for medical consultants and psychological consultants.

Summary of Changes

DI 25220.010 Meets or Medical Equals

Subsection A.2.d. (Who is a Designated Medical or Psychological Consultant?) was revised to reflect the statutory language.

DI 25220.010 Meets or Medical Equals

Step 3 of the sequential evaluation process for children under Title XVI requires a determination whether the child's impairment(s) meets or medically or functionally equals the listings. This section provides the policy for evaluating whether the child's impairment(s) meets or is medically equivalent in severity to a listing,

For information on functional equivalence, see DI 25225.001.

NOTE: The text in section A is regulatory text in the cited sections of the Code of Federal Regulations and is presented without change except to provide POMS citations in place of regulatory citations.

A. Listing of Impairments

1. Listing of Impairments (section 416.925)

a. What is the purpose of the Listing of Impairments?

The Listing of Impairments describes, for each of the major body systems, impairments that are considered severe enough to prevent an adult from doing any gainful activity regardless of his age, education, or work experience, or, for a child, that cause marked and severe functional limitations.

b. How is the Listing of Impairments organized?

The Listing of Impairments consists of two parts:

  • Part A contains criteria that apply to individuals age 18 and over. We may also use part A for individuals under age 18 if the disease processes have a similar effect on adults and children.

  • Part B contains criteria that apply only to individuals who are under age 18; we never use the listings in part B to evaluate individuals who are age 18 or older. In evaluating disability for a person under age 18, we use part B first. If the criteria in part B do not apply, we may use the criteria in part A when those criteria give appropriate consideration to the effects of the impairment(s) in children. To the extent possible, we number the provisions in part B to maintain a relationship with their counterparts in part A.

  • Although the severity criteria in Part B of the listings are expressed in different ways for different impairments, “listing-level severity” generally means the level of severity described in DI 25225.001; that is, “marked” limitations in two domains of functioning or an “extreme” limitation in one domain. (See DI 25225.020 for the definitions of the terms “marked” and “extreme” as they apply to children.) Therefore, in general, a child’s impairment(s) is of “listing-level severity” if it causes marked limitations in two areas of functioning or an extreme limitation in one. However, when we decide whether a child’s impairment(s) meets the requirements of a listing, we will decide that the impairment is of “listing-level severity” even if it does not result in marked limitations in two domains of functioning, or an extreme limitation in one, if the listing that we apply does not require such limitations to establish that an impairment(s) is disabling.

c. How do we use the listings?

  • Each body system section in parts A and B of the Listing of Impairments is in two parts: an introduction, followed by the specific listings.

  • The introduction to each body system contains information relevant to the use of the listings in that body system; for example, examples of common impairments in the body system and definitions used in the listings for that body system. We may also include specific criteria for establishing a diagnosis, confirming the existence of an impairment, or establishing that your impairment(s) satisfies the criteria of a particular listing in the body system. Even if we do not include specific criteria for establishing a diagnosis or confirming the existence of your impairment, you must still show that you have a severe medically determinable impairment(s).

  • The specific listings follow the introduction in each body system, after the heading, “Category of Impairments.” Within each listing, we specify the objective medical and other findings needed to satisfy the criteria of that listing. We will find that your impairment(s) meets the requirements of a listing when it satisfies all of the criteria of that listing, including any relevant criteria in the introduction, and meets the duration requirement.

  • Most of the listed impairments are permanent or expected to result in death. For some listings, we state a specific period of time for which an individual’s impairment(s) will meet the listing. For all others, the evidence must show that your impairment(s) has lasted or can be expected to last for a continuous period of at least 12 months.

  • If your impairment(s) does not meet the criteria of a listing, it can medically equal the criteria of a listing. We explain our rules for medical equivalence in DI 25220.010A.2. We use the listings only to find that you are disabled or still disabled. If your impairment(s) does not meet or medically equal the criteria of a listing, we may still find that you are disabled at a later step in the sequential evaluation process.

d. Can your impairment(s) meet a listing based only on a diagnosis?

No. Your impairment cannot meet the criteria of a listing based only on a diagnosis. To meet the requirements of a listing, you must have a medically determinable impairment(s) that satisfies all of the criteria of the listing.

e. How do we consider your symptoms when we determine whether your impairment(s) meets a listing?

Some listed impairment(s) include symptoms, such as pain, as criteria. DI 24501.021 explains how we consider your symptoms when your symptoms are included as criteria in a listing.

2. Medical equivalence (Section 416.926)

a. What is medical equivalence?

Your impairment(s) is medically equivalent to a listed impairment in the Listing of Impairments if it is at least equal in severity and duration to the criteria of any listed impairment.

b. How do we determine medical equivalence?

We can find medical equivalence in three ways.

  1. 1. 

    If you have an impairment that is described in the Listing of Impairments but you do not exhibit one or more of the findings specified in the particular listing, or you exhibit all of the findings, but one or more of the findings is not as severe as specified in the particular listing, we will find that your impairment is medically equivalent to that listing if you have other findings related to your impairment that are at least of equal medical significance to the required criteria.

  2. 2. 

    If you have an impairment(s) that is not described in the Listing of Impairments, we will compare your findings with those for closely analogous listed impairments. If the findings related to your impairments(s) are at least of equal medical significance to those of a listed impairment, we will find that your impairment(s) is medically equivalent to the analogous listing.

  3. 3. 

    If you have a combination of impairments, no one of which meets a listing described in the Listing of Impairments, we will compare your findings with those for closely analogous listed impairments. If the findings related to your impairments are at least of equal medical significance to those of a listed impairment, we will find that your combination of impairments is medically equivalent to that listing.

c. What evidence do we consider when we determine if your impairment(s) medically equals a listing?

When we determine if your impairment medically equals a listing, we consider all evidence in your case record about your impairment(s) and its effects on you that is relevant to this finding. We do not consider your vocational factors of age, education, and work experience. We also consider the opinion given by one or more medical or psychological consultants designated by the Commissioner.

d. Who is a designated medical or psychological consultant?

A medical or psychological consultant designated by the Commissioner includes any medical or psychological consultant employed or engaged to make medical judgments by the Social Security Administration, the Railroad Retirement Board, or a State agency authorized to make disability determinations. For the necessary qualification for medical consultants and psychological consultants, see DI 24501.001C.

e. Who is responsible for determining medical equivalence?

In cases where the State agency or other designee of the Commissioner makes the initial or reconsideration disability determination, a State agency medical or psychological consultant or other designee of the Commissioner has the overall responsibility for determining medical equivalence. For cases in the disability hearing process or otherwise decided by a disability hearing officer, the responsibility for determining medical equivalence rests with either the disability hearing officer or, if the disability hearing officer's reconsideration determination is changed by SSA, with the Associate Commissioner for Disability Determinations or his or her delegate. For cases at the Administrative Law Judge or Appeals Council level, the responsibility for deciding medical equivalence rests with the Administrative Law Judge or Appeals Council.

B. Determining whether a child's impairment(s) meets or medically equals severity of a listing

Determine whether the child's impairment(s) meets or medically equals the severity of a listed impairment and, if so, whether it meets the duration requirement based on the policies in DI 25220.010B.

  • If the impairment(s) meets or medically equals the severity of a listed impairment, and it meets the duration requirement, find that the impairment(s) causes marked and severe functional limitations and that the child is, therefore, disabled. Record the meets or medical equals finding in Section I of the SSA-538; explain the basis for a medical equivalence finding in the box provided. (See DI 25230.001)

NOTE: Medical equivalence in Title XVI childhood cases in which the child has marked limitations in cognition and speech is discussed in SSR 98-lp and reprinted in DI 24599.001.

  • If the impairment(s) does not meet or medically equal the severity of a listed impairment, consider whether the impairment(s) functionally equals the severity of a listing. (See DI 25225.001)

C. References

DI 24501.001 The Disability Determination Services Disability Examiner, Medical Consultant, and Psychological Consultant Team, and the Role of the Medical Advisor

DI 24501.021 Evaluating Symptoms

DI 24599.001 Determining Medical Equivalence in Title XVI Childhood Disability Claims When a Child Has Marked Limitations in Cognition and Speech

DI 25225.001 Functional Equivalence - Policy (Section 416.926a(a))

DI 25225.020 How We Define Marked and Extreme Limitations (Section 416.926a(e))

DI 25230.001 Explaining Title XVI Childhood Disability Evaluation Determinations

 


DI 25220 TN 2 - Impairment Severity - Not Severe, Meets and Medical Equals - 11/04/2019