Basic (05-86)

DI 34101.015 Listing of Impairments as of July 4, 1967

380. Listing of Impairments, by Body Systems

 

381. Musculoskeletal System

 

1. A. 

   Functional loss may be due to an anatomical loss or to a loss of use of a part due to deformity, adjesions, defective innervation, or other pathodogy. Pain may be an important factor in fuctional loss, but it should be supported by adequate abnormal findings. Evaluations of disability should be supported, where possible, by detailed descriptions of “range of motion” together with pertinent X-ray findings.

2. B. 

   Major joints as used herein refer to hip, knee, ankle, shoulder, elbow, and wrist and hand.

3. C. 

   The measurements of restricted motion and ankylosis used in the listing are based on the technic of measurements described in A Guide to the Evaluation of Permanent Impairment of the Extremities and Back by the Committee on Medical Rating of Physical Impairment, Sepcial Edition, JAMA, February 15, 1958.

    

381.01 Category of Impairments, Musculoskeletal System.

 

381.02 Rheymatoid Arthritis --With:

 

1. A. 

   History of joint pain and swelling in two or more major joints, and morning stiffness persistent on activity; AND

2. B. 

   Signs of joint enlargement or effusion and motion limitation with periarticular muscle wasting in two or more major joints; AND

3. C. 

   X-ray evidence of abnormality of a major joint (i.e., osteoporosis or decalcification or narrowing of joint space) AND one of the following:

   1. 1. 

      anatomical deformity in one major joint, such as subluxation, contracture, bony or fibrous ankylosis, joint instability, ulnar deviation, or hyperextension, with resultant limitation of motion; OR

   2. 2. 

      positive seriologic test for rheumatoid factor; OR

   3. 3. 

      elevated sedimentation rate greater than 20 mm. per hour in females or 10 mm. per hour in males; OR

   4. 4. 

      positive C-reactive protein; OR

   5. 5. 

      polymorphonuclear leukocytosis in synovial fluid aspirate; OR

   6. 6. 

      characteristic histologic changes on biopsy of synovial membrane or subcutaneoud nodule.

       

381.03 Neurogenic Arthritis (e.g., Charcot, Syphillitic) affecting at least one weight bearing joint or one major joint in each of the upper extremities--With:

1. A. 

   Instability or subluxation; AND

2. B. 

   Associated loss of sensory modalities in appropriate distribution.

    

381.04 Hypertrophic (osteo or degenerative), Gouty, Infectious, or Traumatic Arthritis --With:

 

1. A. 

   History of pain and stiffness in involved joints; AND

2. B. 

   X-ray evidence of joint space narrowing and osteophytosis or exotosis, or bony destruction with erosions and cysts, or subluxation, or ankylosis of involved joints AND one of the following:

   1. 1. 

      inability to abduct both arms at shoulders to 90°, OR

   2. 2. 

      ankylosis (fibrous or bony consolidation or fixation) of hip at less than 20 degrees or more than 30 degrees of flexion, measured from neutral positions; OR

   3. 3. 

      ankylosis or fixation of knee at more than 10°from neutral position; OR

   4. 4. 

      limitation of flexation of both hips to 50°or less from neutral position (including ankylosis of both hips at any angle); OR

   5. 5. 

      limitation of flexion of both knees to 30°or less from neutral position (including ankylosis of both knees at any angle); OR

   6. 6. 

      combined involvement of single hip and knee in contralateral extremities, with impairment in each as in 4. and 5. above; OR

   7. 7. 

      X-ray evidence of lumbar spine abnormality as in B. above with motion of dorsolumbar spine limited to 5°or less from normal position and impairment of single hip or knee as in 4. and 5. above.

       

381.05 Disorders of the Spine Due to Any Cause --With:

 

1. A. 

   X-ray evidence in §381.04B. or bilateral ankylosis of sacro-iliac joints and abnormal apophyseal articulations or narrowing of interfacet spaces or calcification of the anterior and lateral ligaments; AND

2. B. 

   Ankylosis or fixation of cervical or dorsolumbar spine at 30°or more of flexion measured from the neutral position.

    

381.06 Tuberculosis of the spine or and major joint--Active

 

381.07 Osteomyelitis

 

1. A. 

   Pelvis, vertebra or a major weight bearing joint or long bone; OR

2. B. 

   With multiple localizations and systemic manifestations such as anemia (hematocrit of 30% or less) or amyloid changes.

    

381.08 Vertebra, fracture of, residuals --With cord or root involvement manifested by sensory and motor loss causing embarrassment of ambulation.

 

381.09 Amputation of; or anatomical deformity (i.e., subluxation, bony or fibrous ankylosis, joint instability, ulnar deviation, or hyperextension) with resultant limitation of:

 

1. A. 

   Both hands: OR

2. B. 

   Both feet; OR

3. C. 

   One hand and one foot; OR

4. D. 

   One hand with blindness in one eye (5/200 visual acuity or 5° visual field); OR

5. E. 

   One foot with blindness in one eye (5/200 visual acuity or 5° visual field).

    

381.10 Amputation of Lower Extremity or Part Thereof

 

--With:

 

1. A. 

   Hemipelvectomy or hip disarticulation; OR

2. B. 

   Inability to use prosthesis effectively, without other assistive device, due to:

   1. 1. 

      secondary vascular disease; OR

   2. 2. 

      secondary neurological complications, e.g., amputation-neurinoma with severe pain or loss of position sense; OR

   3. 3. 

      disorder of contralateral lower extremity causing embarrassment to ambulation.

       

381.11 Nerve Root Compression Syndrom due to Any Cause (i.e., herniated nucleus pulposus, congenital malformations, spondylosis, spondylolisthesis)--With:

 

1. A. 

   Pain and motion limitation in back or neck; AND

2. B. 

   Cervical or lumbar nerve root compression as evidenced by appropriate radicular distribution of sensory, motor, and reflex abnormalities.

    

381.12 Fracture of a Weight-bearing Long 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.

 

382. Special Sense Organs

 

1. A. 

   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 produces loss of the power of orientation rendering it difficult for an individual to move about freely in a strange environment. 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.

2. B. 

   Blindness --Blindness is defined in Section 216(i) of the Social Security Act as “central visual acuity of 5/200 or less in the better eye with the use of correcting lens. An eye in with the visual field is reduced to 5 degrees or less concentric contraction shall be considered . . .as having a central visual acuity of 5/200 or less.” This provision relates to the freeze only and, for the purpose, a finding of disability may be made without regard to individual capacity for work. An individual whose remaining visual acuity or visual field is reduced to, or less than, this definition will be found to have suffered statutory blindness even though he is engaging in SGA. A finding of statutory blindness may not be made on the basis of an equivalent combined loss of visual acuity and visual field, or a loss of visual efficiency.

   In determining whether an individual meets the statutory requirements for a finding of “blindness” the reported visual acuity an visual fields must be considered in terms of the limitations of the tests. Test results in the measurement of vision are not always totally reliable particularly at the level where statutory blindness is concerned. The test results may be influenced by subjective factors such as an individual's condition at a particular time, the circumstances under which the test is performed and the type of test used and do not, therefore, permit such a high degree of accuracy on repeated testing as to allow usage without a rule of tolerance. Since the results of tests for vision are influenced by but do not always reflect these variables, the reported test results may indicate a visual field of 6 degrees, 7 degrees, or 8 degrees from the point of fixation when, in fact, the visual field is restricted to 5 degrees or less, or a visual acuity of 6/200 or 7/ 200 may be reported when the visual acuity is, in fact, 5/200 or less. Thus, a tolerance rule of 3 degrees in evaluating visual fields an 2 feet in evaluating visual acuity will permit a finding of “statutory blindness” when after best correction the reported test results in the better eye are a visual field of 8 degrees or less from the point of fixation or a visual acutity of 7 /200 or less.

3. C. 

   Central Visual Acuity --Disability due to loss of central visual acuity may be caused by impaired distant or near vision. Remaining visual acuity will usually be based on central visual acuity for distance of the better eye, as corrected by regular ophthalmic lenses, using the Snellen test chart. However, consideration should also be given to findings on ophthalmological examination, and the record of refraction. In unusual cases, where the loss of central visual acuity for distance does not accurately reflect the extent of impairment because corrected near vision of the better eye is of little or no value, there may nevertheless be a basis for a finding of disability depending on the facts in the individual case. Such cases should be supported by measurement of near, as well as distant vision, with record of refraction. (Refer to Tables No. 1 and 2, §382.11, for percentages of central visual efficiency corresponding to central visual acuity notations for distant and near vision.)

   Generally, reports of visual acuity will be expressed in standard terms using the Snellen test chart. This permits a direct reference to the listing for visual acuity in section 382.04 or to the requirements for statutory blindness in section 382B. Sometimes, however, reports may reflect a reduction in the distance between the test chart and the individual being tested and a reading such as 10/100 may be encountered. Also, examiners will occasionally use test letters even larger than the conventional 20/200 size letter and report findings such as 20/800, etc. These numerical designations represent the distance between the chart and the person being tested (numerator) and the distance at which the letters should be seen by the normal eye (denominator), These expressions of visual acuity are not mathematical fractions of visual functions and cannot be compared as such; it is incorrect to reason that if 20 /20 visions equals one, then 20/40 vision is only one-half as good, However, it is possible to closely determine, from unusual reports of visual acuity, an individual's acuity at 20 feet or in relation to the 200 letter of the Snellen chart by multiplying or dividing the numerator and the denominator by the same number. For example, a reported visual acuity of 10/100 is essentially a visual acuity of 20/200 and a reported visual acuity of 20/ 800 is essentially a visual acuity of 5/200.

   Regular ophthalmic lenses do not include contact lenses or other special visual aids. If best correction obtained by regular ophthalmic lenses does not result in remaining visual efficiency (see F. below) of greater than 20% visual efficiency, the case may be allowed in accordance with §382.06, unless an examining ophthalmologist recommends the use of special lenses (e.g., contact or telescopic lenses), in which case consideration should be given to the improvement in visions thereby attainable. The file should contain specific evidence from the examining ophthalmologist as to the extent to which the special lenses restore useful vision to the claimant.

4. D. 

   Field of Vision --Disability due to loss of peripheral vision may result if there is severe contraction of the visual field. The contraction may be either symmetrical or irregular. The extent of the remaining visual field will be determined by usual perimetric methods, utilizing a white target which subtends a 0.5-degree angle (3mm. white disc at a distance of 330 mm.) under illumination of not less than 7 foot-candles. The result should be plotted on an ordinary visual field chart on each of the eight 45-degree principal meridians. (Refer to Tables No. 3 and 5, §382.11, for definitions of terms and chart of visual fields.)

5. E. 

   Muscle Function --Paralysis of the third cranial nerve producing ptosis, paralysis of accommodation, an dilatation 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 may be disabling, providing it is bilateral. A finding of disability based primarily on impaired muscle function should be supported by pathological findings, measurement of ocular mobility by standard perimetric and tangent screen testing or muscle function chart.

6. F. 

   Visual Efficiency --Disability due to loss of visual efficiency may be caused by disease or injury resulting in both a reduction of central visual acuity and visual field defects. 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, 3, and 4 § 382.11.)

7. G. 

   Special Situations --Aphakia represents a visual handicap in addition to the loss of central visual acuity. In cases of binocular aphakia, the central visual efficiency of the better eye may be accepted as 75% of its value. In cases of monocular aphakia, where the better eye is aphakic, the central visual efficiency may be acceptable as 50% of its value. (Refer to Table No. 1, §382.11.)

   Glaucoma refers to a group of diseases characterized by abnormal elevation of intraocular pressure and anatomic and functional changes resulting from abnormal pressure. Although acute glaucomatous attacks may produce a rapid and severe loss of vision, prompt treatment usually results in restoration of useful vision. The gradual loss of vision caused by chronic glaucoma, however, is permanent. Invariably, peripheral visual field defects occur before a reduction in central visual acuity.

   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.

8. H. 

   Determination of Hearing Loss --While many deaf persons adjust well to social living and engage in substantial gainful activity, others are incapacitated by less than total deafness. Since the most important aspect of hearing is the ability to hear and understand speech correctly, impairment in ability to hear sound alone may not reveal the full extent of functional hearing loss, because speech consists of many components. Although there is usually a close parallel between inability to understand speech, the two may diverge widely, with a moderate loss of auditory acuity being complicated by serious difficulty in speech discrimination.

   Accordingly, 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 tests 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.

    

382.01 Category of Impairments, Special Sense Organs

 

382.02 Glaucoma --Evaluate impairment of central visual acurity and visual fields under §§382.04, 382.05, or 382.06 below.

 

382.03 Cataract, developmental and degenerative --Evaluate remaining vision under §§382.04, 382.05, or 382.06 below.

 

382.04 Central visual acuity, impairment of --Remaining vision in better eye after best correction with regular ophthalmic lenses, 20 /200 or less.

 

382.05 Visual fields, impairment of --Contraction fo the visual fields:

1. A. 

   To 10 degrees or less from the point of fixation; OR

2. B. 

   So the widest diameter subtends at an angular distance not greater than 20 degrees; OR

3. C. 

   To 20% or less visual field efficiency.

    

382.06 Loss of visual efficiency --Visual efficiency of better eye after best correction with regular ophthalmic lenses, 20% or less.

 

382.07 Complete Homonymous hemianopsia

 

382.08 Ophthalmoplegia total, bilateral

 

382.09 Menieres syndrome --Severe; with frequent and typical attacks, vertigo, deafness and cerebellar gait.

 

382.10 Hearing Impairments, not correctible by a hearing aid manifested by:

1. A. 

   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

2. B. 

   No more than 40% 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).

    

382.11 Tables

Table No 1--Percentage of Central Visual Efficiency Corresponding to Central Visual Acuity Notations for Distance

 

Table No. 2--Percentage of Central Visual Efficiency to Central Visual Acuity Notations for Near

 

Table No. 3--Chart of Visual Field Showing Extent of Normal Field and Method of Computing Percent of Visual Field Efficiency

 

Table No. 4--Percent of Remaining Visual Efficiency (One Eye)

 

Table No. 5--Technical Definitions

Table No. 1 - Percentage of Central Visual Efficiency Corresponding to Central Visual Acuity Notations for Distance

*Denoting each constituent part of test character. When the visual angle of each constituent part is multiplied by 5, the product is the visual angle of entire test character.

+For purposes of calculation of the % of central visual efficiency, 100% is used. This does not consider the fact that the average normal person usually has a visual acuity of 20/16 corrected by ophthalmic lenses.

Central visual efficiency is reduced by 25% in binocular aphakia and 50% in monocular aphakia, where the better eye is aphakic. If central visual efficiency of the better eye is 40%, central visual efficiency (binocular aphakia) is 75% of 40% or 30%. In case of monocular aphakia, central visual efficiency would be 50% of 40%, or 20%.

Table No. 2 - Percentage of Central Visual Efficiency to Central Visual Acuity Notations for Near

*Denoting each constituent part of test character. When the visual angle of each constituent part is multiplied by 5, the product is the visual angle of entire test character.

 

Table No. 3--Chart of Visual Field Showing Extent of Normal Field and Method of Computing Percent of Visual Field Efficiency

1. 1. 

   Diagram of right eye illustrates extent of normal visual field as tested on standard perimeter at 3/330 (3 mm. white disc at a distance of 330 mm.) under 7 foot-candles illumination. The sum of the 8 principal meridians of this field total 500 degrees. (See Table No. 5 for definition of terms)

2. 2. 

   The percent of visual field efficiency is obtained by adding the number of degrees of the 8 principal meridians of the contracted field and dividing by 500. Diagram of left eye illustrates visual field contracted to 30 degrees in the temporal and down and out meridians and to 20 degrees in the remaining 6 meridians. The percent of visual field efficiency of this field is: 6 ×20+2 ×30=180÷500=0.36 or 36% remaining visual field efficiency, or 64% loss.

Table No. 4 --Percent of Remaining Visual Efficiency (One Eye)

1. 1. 

   The product of the % of remaining central visual efficiency and the % remaining visual field efficiency -% of remaining visual efficiency.

2. 2. 

   Find % of remaining central visual efficiency in left hand column an % of remaining visual field efficiency in row at bottom of table. The point where this row and column intersect is the remaining visual efficiency.

3. 3. 

   Any combination falling below the dotted line represents 20% or less remaining visual efficiency or an 80% or more loss of visual efficiency.

Table No. 5 --Technical Definitions

Angular distance--The distance in degrees of arc that the field of vision subtends the visual field chart, the sum of the two meridians in the same plane equals the angular distance.

Concentric contraction--A concentric contraction of the visual fields is a contraction affecting all parts of the periphery alike. This definition excludes sector-shaped and irregular contraction.

Diameter--The sum of the two radii in the same axis. (For example the sum of the nasal temporal radii of a visual field.)

Fixation point--The target on which the gaze is fixed. On the visual field chart, this point is the center of the concentic circles, the point at which the radii of the circles converge.

Meridian--The meridian on a visual field chart is a line radiating from the point of fixation. In visual field testing, the boundaries of the visual field are usually determined by ascertaining the extent of vision every 45 degrees. These 8 radii of the visual field chart are known as the 8 principal meridians.

Quadrant--One quarter of the visual field.

Visual angle--The angle formed by two lines drawn from the extremities of the object through the nodal point of the eye.

Visual field--The area in which objects are visible when the eye is fixed. The field of vision in a given plane includes the field measurement on either side of the point of fixation in the same plane, or the sum of the 2 radii which form the diameter of a visual field chart.

Visual field efficiency--An estimate in percentage of the efficiency of the remaining visual field.

 

383. Respiratory System

1. A. 

   Cause of Disability --The disability produced by respiratory disease usually results from chronic or recurrent infection or from pulmonary insufficiency or a combination of these factors.

2. B. 

   Pulmonary Tuberculosis --Tuberculosis is a communicable disease and, as such, disability due to tuberculosis is determined primarily on the basis of activity of the disease. Individuals who meet the criteria described in the listing for pulmonary tuberculosis (§383.08) will be found to have a disabling impairment which is expected to last for a period of at least 12 months. Other medical factors, including proposed surgery, will not militate against such a finding.

   Documentation --Activity of tuberculosis (active, inactive, quiescent) and extent of pulmonary lesion on roentgenogram are defined in the “Diagnostic Standards and Classification of Tuberculosis” (NTA, 1961, pp. 39-41). Tuberculosis will be considered to be present only where typical bacilli, M. Tuberculosis, have been demonstrated by growth in culture or by guinea pig inoculation. Where sputa (gastrics) have not been cultured or reported monthly for six months, as required for definition of activity, a presumption will be made that the intervening specimens were negative, if a current sputum is negative. The initial report should contain all the culture findings available with dates of collection of specimens. The date of the positivity or negativity of a specimen is the date of its collection. If the date of collection of a specimen is not reported, it will be assumed that the specimen was collected eight weeks prior to the date of the report of culture. Suspected or questionable cavitary disease identified on the basis of a conventional PA 14 ×17 inch film will be considered to be non-cavitary unless confirmed by laminograms. Generally, individuals with “inactive” or “quiescent” disease are not prevented from engaging in substantial gainful activity. Impairment of pulmonary function due to extensive pulmonary tuberculosis may be evaluated under the guides for chronic obstructive airway disease.

   Onset --The onset of the impairment due to tuberculosis will be the date the X-ray was taken or the sputum (gastric) was collected on the basis of which a diagnosis of tuberculosis was made; or the date of work cessation, if work ceased within 3 months preceding diagnosis by X-ray or bacteriologic finding. If work cessation preceded diagnosis by more than 3 months, onset of impairment due to tuberculosis will be considered to be 3 months preceding the date of X-ray or the date the sputum was collected.

3. C. 

   When a Respiratory Impairment is Episodic in Nature, as may occur in complications of bronchiectasis and mycotic asthma infections of the lung, the frequency of severe episodes is the criterion for determining level of impairment.

4. D. 

   Cor Pulmonale --Chronic cor pulmonale as used in § 383.12 refers to a condition in which the right ventricle is enlarged as a consequence of a primary respiratory disease. Therefore, the clinical diagnosis of the respiratory disorder must be established by history, physical findings and chest X-ray. Right ventricular enlargement or outflow tract prominence may be difficult to detect on routine PA film, particularly in the presence of chronic obstructive airway disease. Consequently, lateral and oblique films or chest fluoroscopy should be obtained, unless cardiac enlargement is established by the PA film, as per §384.02.

5. E. 

   Pulmonary insufficiency is a deleterious alteration in the normal physiologic function of the lungs and is usually manifested clinically by a complaint of shortness of breath (dyspnea) and by a decrease in exercise tolerance. Obstruction to the flow of air into and out of the lungs or an inability of the lungs to oxygenate blood normally are examples of abnormal function. The various physiologic defects that contribute to pulmonary insufficiency can be measured objectively and accurately when appropriate tests are properly performed. Therefore, these tests are used to assess the severity of impairment. There is no one test that measures all types of physiolgic defects. The tests include in the listings represent those that will best reflect the degree of pulmonary insufficiency present in the disease categories in which they are included.

Documentation of Pulmonary Insufficiency --Spirometric studies for evaluation under Tables I, II, III, IV, and VI must be reported in liters. The MVV (maximum voluntary ventilation), sometimes called the MBC (maximum breathing capacity), is defined as the maximum volume of air that can be breathed per minute. The MVV or the MBC reported should represent the observed value and should not be caluculated from FEV ₁ . The FEV₁ (one-second forced expiratory volume, one-second forced vital capacity) is defined as the maximal volume of air that can be forcibly exhaled during the first second starting from full inspiration. The VC (vital capacity) or FVC (forced vital capacity) is defined as the maximal volume of air that can be exhaled starting from full inspiration. Reported values should represent the largest of at least three attempts. Values must be expressed in liters or liters per minute. They should be accompanied, whenever possible, by appropriately labeled spirometric tracings and by a statement as to the applicant's cooperation and effort. Where effort is less than optimal, results should be interpreted with great caution. Studies should not be performed during or soon after an acute respiratory illness. If wheezing is present on auscultation of the chest, studies should be performed following administration of nebulized bronchodilator.

1. F. 

   Obstructive Airway Disease --The three tables to be used for evaluation of cases involving chronic obstructive airway disease are Tables I, II, and III in §383.02. They relate to an individual's physical capacities to do light, medium, or heavy work as defined in the Dictionary of Occupational Titles (Vol. 2, App. B, pages 654-655.

Table I --If a claimant has an MVV and FEV₁ equal to, or less than, those specified in Table I, he may be found to have an impairment of pulmonary function severe enough to preclude any substantial gainful activity on medical considerations alone. Hence, consideration of vocational factors is not necessary.

Table II --If a claimant's MVV or FEC₁ are greater than specified in Table I but equal to, or less than, those specified in Table II, he has sufficiency breathing capacity to engage in light, but not medium or heavy work activity. Therefore, consideration of vocational factors would be necessary to determine whether the individual has the vocational capabilities for light work activity.

Table III --If a claimant has an MVV and FEV₁ greater than specified in Table II but equal to or less than specified in Table III, he has sufficient breathing capacity to do light and medium , but not heavy work activity. Consideration of vocational factors would be required to determine whether the individual has the vocational capabilities for light or medium work activity.

The individual who has an MVV and FEV₁ greater than shown in Table III has the breathing capacity for light, medium, and heavy work. Therefore, in the absence of an impairment other than chronic obstructive airway disease, vocational assessment will not ordinarily be needed since his respiratory capacity is sufficient to enable him to engage in any substantial gainful activity.

 

383.01 Category of Impairments, Respiratory System

 

383.02 Chronic Obstructive Airway Disease --(chronic bronchitis, chronic asthmatic bronchitis or pulmonary emphysema with or without X-ray findings)--With:

Spirometric evidence of airway obstruction demonstration by MVV and FEV₁ both equal to, or less than, the values specified in Tables I, II, or III corresponding to the applicant's height. The table should be applied as specified in §383 F. above.

 

383.03 Bronchial Asthma, Allergic, or Atopic (not due primarily to heart disease or bronchial infection)--Evaluate the resulting impairment according to §383.02.

 

383.04 Diffuse Pulmonary Fibrosis (sarcoidosis, Hamman-Rich Syndrome, idiopathic interstitial fibrosis, and similar diffuse fibroses substantiated by chest X-ray or tissue diagnosis. This category does not include cases of bronchitis or emphysema with incidental scarring or scattered parenchymal fibrosis on X-ray)--With one of the following:

1. A. 

   Total vital capacity equal to, or less than, values specified in Table IV below corresponding to the applicant's height.

Table IV

OR

 

1. B. 

   Diffusing capacity of the lungs for carbon monoxide less than 6 ml/mm Hg /min. (steady-state methods) or less than 9 ml/mm Hg/min. (single-breath methods) or less than 30% of predicted normal. (All methods--actual values and predicted normal for the method used should be reported); OR

2. C. 

   Arterial oxygen saturation at rest and simultaneously determined arterial pCO₂ equal to or less than the values specified in Table V.

Table V

 

383.05 Other Restrictive Ventilory Disorders (e.g., Kyphoscoliosis, thoracoplasty, pulmonary resection)--With:

Total vital capacity equal to or less than values specified in Table VI corresponding to the applicant's height.

 

383.06 Pneumoconiosis (demonstrated by X-ray evidence)--With:

1. A. 

   Nodular or focal fibrosis--evaluated under the guides for chronic obstructive airway disease (§383.02); OR

2. B. 

   Interstitial or disseminated fibrosis--evaluate under guides for pulmonary fibrosis (§383.04); OR

3. C. 

   Where A and B are mixed or cannot be differentiated, evaluate under §383.02 or 383.04

    

383.07 Bronchiectasis (demonstrated by radio-opaque material)--With:

1. A. 

   Episodes of acute bronchitis or pneumonia or hemoptysis (more than blood streaked sputum) occurring at least once every two months; OR

2. B. 

   Impairment of pulmonary function due to extensive disease should be evaluated under the Listing for chronic obstructive airway disease (§ 383.02) or , where extensive fibrosis is evident of chest film, under the guides for pulmonary fibrosis (§383.04).

    

383.08 Pulmonary Tuberculosis (establish by positive bacteriologic findings)--With:

1. A. 

   Positive bacteriologic findings more than 3 months following onset of disability; OR

2. B. 

   Serial X-ray evidence of increasing extent or activity of lesion more than 3 months following onset of disability; OR

3. C. 

   Far-advanced disease with cavitation and positive bacteriologic findings at any time following onset of disability; OR

4. D. 

   Impairment of pulmonary function due to extensive disease should be evaluated under the listings for chronic obstructive airway disease (§ 383.02) or , where extensive fibrosis is evidence on chest film, under the guides for pulmonary fibrosis (§383.04).

    

383.09 Pulmonary Infection Caused by Atypical Mycobacteria (definition of activity and instructions for reporting sputa and X-rays should follow the instructions under pulmonary tuberculosis in § 383.08)--With:

1. A. 

   Culture of atypical mycobacteria from sputa more than 3 months following the onset of disability; OR

2. B. 

   Serial X-ray evidence of increasing extent or activity of lesion more than 3 months following onset of disability; OR

3. C. 

   Impairment of pulmonary function due to extensive disease should be evaluated under the listings for chronic obstructive airway disease (§ 383.02) or , where extensive fibrosis is evidence on chest film, under the guides for pulmonary fibrosis (§383.04).

    

383.10 Mycotic Infection of Lung --With:

1. A. 

   Culture of specific organisms from sputa and serial X-ray evidence of changing extent or activity of lesion, both occurring more than 3 months following onset of disability; OR

2. B. 

   Culture of specific organisms from Sputa at any time following onset of disability and current X-ray evidence of a lesion and episodes of hemoptyis occurring at least once every two months; OR

3. C. 

   Impairment of pulmonary function due to extensive disease should be evaluated under the Listings for chronic obstructive airway disease (§ 383.01) or, where extensive fibrosis is evident on chest film, under the guides for pulmonary fibrosis (§383.04).

    

383.11 Organic Loss of Speech --With:

1. A. 

   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

2. B. 

   Central nervous system lesion resulting in severe sensory or motor aphasia paralleling the speech impairment under A. above.

    

383.12 Cor Pumonale --With:

1. A. 

   Congestive heart failure (evaluate according to §383.02); OR

2. B. 

   Right-sided congestive failure as evidenced byperipheral edema and liver enlargement and right ventricular enlargement or out-flow tract prominence on X-ray or fluoroscopy.

    

384. Cardiovascular System

1. A. 

   There is no single clinical test which will measure accurately the functional capacity of the heart. This is best determined by the ability of the individual to engage in a given degree of activity without producting significant signs and symptoms. Symptoms alone are not conclusive evidence of disability. Symptoms must be supported by objective clinical findings such as cardiac enlargement, ECG changes, edema, etc.

   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. The listings spell out a level of severity in terms of symptoms, signs, and laboratory findings. It is recognized, however, that the listings do not include all possible findings. The exercise of judgment is needed to determine whether the impairment described in the medical record parallels the level of severity described in the listing.

2. B. 

   Mild exertion is used in the listings to refer to such activities as walking several blocks at a rate of 2-3 miles per hour, using public transportation, doing small chores, and engaging in the ordinary activities of daily living. Some examples of the latter would include driving an automobile and performing household tasks, such as washing dishes and sweeping the floor, as well as the personal care activites of washing, dressing, shaving, etc. Symptoms developing on such activities will be held to occur on mild exertion.

   Chest pain by itself and in the absence of corroborative evidence is insufficient to warrant a finding of disability. The history should be meticulously recorded in the file and should contain an approximate date of onset. The description of the chest discomfort should include the quality of the discomfort (tight, constricting, oppresive, vise-like, or burning), its intensity, location, and radiation. The regularity and promptness of relief by rest and nitroglycerin should be specifically described. The relationship of exertion should be carefully reported with a specific description of the amount of exertion required to produce pain, expressed in terms of numbers of level blocks walked or flights of stairs ascended at normal speed. Any relationship to eating and emotional stress should be indicated. If there is any pain at rest or angina decubitus, this shoud be described in great detail to permit differentiation from extracardiac chest pain. Common conditions which may simulate angina pectoris include cervical or dorsal arthritis or disc, chest wall syndrome, hyperventilation syndrome, esophageal or gastroduodenal or gallbladder disorders. There should be some objective sign or laboratory finding to validate the subjective complaint and corroboration by ECG evidence is preferred. All ECG tracings preferably should be a part of the file.

   Heart block must be evaluated in terms of impairment of function. This will usually take the form of cardiac syncope which must be differentiated from syncope due to other causes such as vasovagal attacks, hysterical episodes, and epilepsy. Cardiac syncope is most frequently associated with sudden alterations in rate or rhythm such as heart block of high degree or extreme paroxysmal tachycardia. In addition, persons with high grade aortic stenosis may develop syncope or even epileptiform seizures on effort.

3. C. 

   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, syphilitic heart disease). It is a clinical state due to decreased muscular effectiveness of the heart characterized mainly by cardiac enlargement, shortness of breath, and/or peripheral edema.

4. D. 

   Arteriosclerotic heart disease or coronary artery disease is by far the most common cause of myocardial ischemia. This is due to a narrowing of the coronary arteries by the arteriosclerotic process. It constitutes a clinical spectrum ranging from complete compensation and absence of pain under heavy load to severe angina or decompensation at rest. The degree of functional impairment may range from none to total, depending on the signs and symptoms produced by activity.

5. E. 

   Hypertensive vascular disease produces disability when it causes complications in one or more of the four main end organs--the heart, the brain, the kidneys, the eyes (retina). This may occur singly or in combination and to varying degrees in the different end organs.

6. F. 

   Diseases of the Arteries and Veins --The conditions considered in the listing related to the peripheral vessels of the extremities. However, disease of the major branches are also considered. These diseases are reflected in findings such as failure of visualization of segments of the arterial system of an extremity on an arteriogram, neurological changes (ischemic neuritis), or absent peripheral arterial pulis aline, ulceration, gangrene, persistent coldness, and white or bluish discoloration of the extremities or parts thereof, and edema.

7. G. 

   Collagen--vascular disorders --Periarteritis nodosa (polyarteritis, necrotizing angiitis), dermatomyostis (polymyositis), systemic lupus erythematosus, an scleroderma (progressive systemic sclerosis) constitute a group of clinical syndromes usually known as diseases of connective tissue or collagen--vascular disesase. While these syndromes have certain pathological features in common with widespread damage in the connective tissue, each presents a more or less distinct clinical pattern. They are as a group characterized by constitutional manifestations in addition to local lesions usually involving blood vessels, joints, heart, skin, muscles, and the supporting tissues of the viscera. The clinical features are largely determined by the distribution and rate of development of these lesions.

8. H. 

   Surgical Procedures in Heart Disorders --The treatment of congenital or acquired heart disease by means of surgery, including insertion of a pacemaker, is relatively new and experimental. The amount of function restored and the time required to effect improvement in an individual treated by these methods varies considerably with the nature of the disorder, the type of surgery involved and many other individual factors. Therefore, in cases involving heart surgery, the individual will be deemed to be under a disability for at least 12 months after the operation. How long the individual may have been disabled prior to the operation will be determined by all the evidence of record. Likewise, a finding as to the individual's ability or inability to engage in substantial gainful activity 12 or more months after the operation will require documentation and evaluation of all appropriate factors.

    

384.01 Category of Impairments, Cardiovascular System

 

384.02 Congestive Heart Failure (due to any cause)--Evidenced by:

Cardiac enlargement on teleroentgenogram (6 foot film) showing cardiothoracic ration of 55% or greater, or equivalent enlargement of the transverse diameter of the heart, AND one of the following:

1. A. 

   Shortness of breath on mild exertion; OR

2. B. 

   Paroxysmal nocturnal dyspnea; OR

3. C. 

   Orthopnea; OR

4. D. 

   Moderate peripheral edema; OR

5. E. 

   Pulmonary edema; OR

6. F. 

   Liver enlargement (not due to other causes).

    

384.03 Hypertensive Vascular Disease (apply this section if diastolic pressures are consistently in excess of 100 mm. Hg.)--With:

1. A. 

   Hypertensive retinopathy with hemorrhages or exudates or papilledema; OR

2. B. 

   Impaired renal function on repeated examination evidenced by BUN 30 mg.% or greater, or equivalent elevation of non-protein nitrogen, or blood urea, or creatinine; OR

3. C. 

   Hypertenstion cerebrovascular damage with permanent motor or sensory defect or organic brain damage of any degree; OR

4. D. 

   Congestive heart failure (see §384.02); OR

5. E. 

   Angina pectoris (see §384.04).

    

384.04 Arteriosclerotic Heart Disease --With:

1. A. 

   Mycardial infraction as evidenced by ECG or adequate clinical reports and complicated by angina on mild exertion; OR

2. B. 

   Persistent heart block or other arrhythmia as evidenced by ECG with Stokes-Adams attacks; OR

3. C. 

   Angina pectoris on mild exertion, and one of the following:

   1. 1. 

      electrocardiographic abnormalities, in the absence of digitalis effect, such as, but not limited to, ischemic ST segment (1 mm. or more depression) or T-wave inversion, or second or third degree heart block or left bundle branch block, or left ventricular hypertrophy; OR

   2. 2. 

      standardized eletrocardiographic exercise test showing ST segment depression (exclusive of juctional depression) of 1 mm. or more in any lead, or development of bundle branch block; OR

   3. 3. 

      diastolic hypertension in excess of 100 mm. Hg. or greater on repeated examination; OR

   4. 4. 

      cardiac enlargement on X-ray (as described in §384.02); OR

   5. 5. 

      aortic valvular disease as evidenced by appropriate basilar murmurs and peripheral vascular signs; OR

   6. 6. 

      obstruction or narrowing of coronary vessels observed on angiography (to be used only when previously obtained independent of social security disability evaluation); OR

   7. 7. 

      intermittent claudication on exertion with signs of peripheral vascular insufficiency, such as diminished peripheral pulsations, pallor and coldness of lower extremities.

4. D. 

   Congestive heart failure (see §384.02).

    

384.05 Rheumatic Heart Disease --Evaluate according to the criteria for congestive heart failure (see §384.02), angina pectoris or heart block or other arrhythmias (see §384.04), or permanent cerebrovascular damage of any degree.

 

384.06 Syphilitic Heart Disease --Evaluate according to criteria for congestive heart failure (see §384.02), angina pectoris or heart block or other arrhythmias (see §384.04).

 

384.07 Cor Pulmonale --With:

1. A. 

   Congestive heart failure (see §384.02); OR

2. B. 

   Right-sided congestive failure as evidenced by peripheral edema, and liver enlargement, and right ventricular enlargement or out-flow tract prominence on X-ray or fluoroscopy.

    

384.08 Surgery for Congenital or Acquired Heart Disease (surgical treatment of heart valves or other lesions or insertion of a pacemaker)--Consider under a disability for at least 12 months after the operation and thereafter evaluate the residual impairment according to the listing for the appropriate body system.

 

384.09 Aneurysm of Aorta or Branches (demonstrated by X-ray evidence)--With:

1. A. 

   Persistent dyspnea, pain, and cough; OR

2. B. 

   Repeated hemoptysis; OR

3. C. 

   Syncopy

    

384.10 Raynaud's Disease --With progressive course, frequent recurrences, and trophic changes.

 

384.11 Chronic venous insufficiency, lower extremity --With chronic obstruction of the deep venous return, superficial varicosities, recurrent ulceration, and extensive brawny edema.

 

384.12 Arteriosclerosis Obliterans or Thrombo-angiitis Obliterans --With:

1. A. 

   Intermittent claudication on mild exertion with absence of peripheral arterial pulsations below the femoral artery or failure of visualization of a major peripheral artery on arteriogram; OR

2. B. 

   foot, leg, thigh amputation due to peripheral vascular disease, with evidence of peripheral vascular disease in the remaining or other extremity.

    

384.13 Polarteritis Nodosa (periarteritis) (established by biopsy)--With signs of generalized arterial involvement.

 

384.14 Disseminated Lupus Erythematosus (established by a postivie LE preparation or biopsy)--With frequent exacerbations demonstrating involvement of renal, or cardiac, or pulmonary, or gastrointestinal, or central nervous systems.

 

384.15 Scleroderma (Progressive Systemic Sclerosis) the diffuse or gerneralized form--With:

1. A. 

   Advanced limitation of use of hands due to sclerodactylia or limitation in other joints; OR

2. B. 

   Visceral manisfestations of digestive, cardiac, or pulmonary impairment.

    

385. Digestive System

1. A. 

   Diseases and disorders of the digestive system resulting in disability frequently do so by reason of interference with the nutrition of the body as a whole. Such interference may arise as a result of lowered food intake, incomplete digestion, or abnormal excretion of intestinal contents. The severity of the concomitant malnutrition may be indicated by loss of weight, loss of muscle tone, and anemia.

2. B. 

   A colostomy does not of itself ordinarily impose marked restriction of activity if the individual is able to manage diet and irrigation. An ileostomy frequently requires a bag due to the character of the discharge which is fluid. However, restriction of ordinary activity is not always necessary with a properly fitted bag.

    

385.01 Category of Impairments, Digestive System

 

385.02 Tongue, loss of whole or part --With marked impairment of mastication and with inability to communicate by speech.

 

385.03 Esophagus, stricture of --Permitting passage of liquids only, with marked impairment of general health, loss of weight and body vigor.

 

385.04 Ulcer, peptic --Severe; with continuous manifestions of marked anemia, malnutrition and impairment of health, and with frequent and prolonged episodes of vomiting such as exhibited by marginal gastrojejunal ulcers and supported by X-ray and laboratory findings.

 

385.05 Liver, cirrhosis of --Severe; With:

1. A. 

   Ascites requiring frequent tapping; OR

2. B. 

   Frequent recurring hemorrhage from esophageal varices, marked loss of weight and impairment of general body vigor.

    

385.06 Jaundice --Severe; persistent; from whatever cause.

 

385.07 Cholecystitis and Cholelithiasis --Severe; with frequent episodes of pain and gastrointestinal symptoms or accompanied by jaundice.

 

385.08 Colitis, ulcerative --Severe; With:

1. A. 

   Marked malnutrition, anemia, and general debility; OR

2. B. 

   Serious complications.

    

385.09 Intestine, fistual of, persistent --With copious, frequent fecal discharge.

 

385.10 Anus impairment of sphincter control --With complete loss of sphincter control.

 

385.11 Rectum and anus, stricture of --Requiring colostomy or ileostomy with copious frequent fecal discharge not managed by prescribed therapy (diet, bag, etc.)

 

385.12 Ventral Hernia --Massive, with severe diastasis of muscle, weakening of muscular and fascial support, and of such nature that prosthesis does not adequately support the abdominal wall.

 

385.13 Hiatus Hernia --With severe symptoms.

 

386. Genito-Urinary System

1. A. 

   The most frequent disabling conditions under this system relate to disturbances of kidney functions giving rise to symptoms and findings commonly associated with nephritis. The glomerular type of nephritis, usually preceded by or associated with severe infectious disease, is sudden in onset, and may clear up entirely or become chronic. The nephrosclerotic type, related to hypertension or arteriosclerosis, develops slowly with fewer laboratory findings and usually follows a progressive course.

2. B. 

   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 an ileal diversion are in the area of renal impairment such as progressive hydronephrosis or pyelonephritis with constitutional symptoms.

    

386.01 Category of Impairments, Genito-Urinary System

 

386.02 Impairment of Renal Function due to any cause (e.g., nephritis, nephrolithiasis, polycystic disease, uretheral obstruction, etc.)--With:

1. A. 

   Impaired renal function on repeated examinations evidences by BUN or 30 mg./100 ml. or greater ( or equivalent elevation of NPN or blood urea or creatinine); OR

2. B. 

   Cardiac complication (evaluate according to §384 ff.)

    

386.03 Kidney, removal or functional loss of one --With nephritis, infection or other pathology in remaining kidney. Evaluate according to §386.02 above.

 

386.04 Permanent Urinary Diversion --Suprapublic cystostomy or ileal diversion with progressive hydronephrosis or pyelonephritis evidenced by constitutional symptoms and signs.

 

386.05 Urethra, fistula of --Multiple urethroperineal.

 

386.06 Tuberculosis of the Genito-Urinary Tract, with active disease as evidenced by:

1. A. 

   Tubercle bacilli more than 3 months following onset of disability; OR

2. B. 

   Increasing activity or extent of lesion on cystoscopy or serial pyelography more than 3 months following onset of disability.

    

387. Hemic and Lymphatic System

1. A. 

   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 shoud be evaluated according to the criteria listed under the appropriate sections. The major complications of hematologic disorders are congestive heart failure or angina associated with chronic anemia, or occlusion of coronary arteries (§384), hepatic disease or biliary obstruction with jaundice (§385), renal disease ( §386), and infiltrations or pathologic fractures of bones (§ 381). Occlusions of cerebral vessals or hemorrhage into the central nervous system also represent a common complication of hematologic disease. Since further damage to the central nervous system may be expected to occur because of the primary hematologic disease, these individuals should not be required to meet a level of severity as listed under the Nervous System (§391). Where a permanent motor or sensory deficit or organic brain syndrome of any degree exists which is caused by a persisting hematologic disease, the individual will be found to have a disabling impairment which is expected to last for a period of at least 12 months.

   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 twelve months.

   The level of laboratory findings cited in the listings, 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.

    

387.01 Category of Impairments, Hemic and Lymphatic System

 

387.02 Chronic Anemias --With hematocrit of 30% or less. Evaluate the resulting impairment according to the listings for the affected body system.

 

387.03 Hemolytic Anemia (due to autoimmune antibodies or other causes)--With hematocrit of 30% or less AND:

1. A. 

   Serum bilirubin of 1.5 mg/100 ml. or greater; OR

2. B. 

   Reticulocyte count of 4% or greater.

    

387.04 Paroxysmal Nocturnal Hemoglobinuria --With hematocrit of 30% or less and persistent hemolysis with development of pancytopenia and frequent blood transfusion reactions.

 

387.05 Hemoglobinopathies (Sickle cell disease, Thalassemia, etc.)--With hematocrit of 30% 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.

 

387.06 Purpuras (idiopathic thrombocytopenic purpuras, etc.)

1. A. 

   Generalized persistence purpura and at least one major spontaneous hemorrhage from body orifices requiring blood transfusion within the 6 months following the onset of disability; OR

2. B. 

   Blood platelet count of 40,000/cu. mm. or less.

    

387.07 Hereditary Telangiectasis --With frequent hemorrhages from body orfices requiring blood transfusion at least every 3 months.

 

387.08 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.

 

387.09 Polycythemia --Secondary and Primary (Polycythemia vera). With hematocrit of 55% or more in males or 50% or more in females, and a rapid rise in hematocrit after prescribed therapy. Evaluate the resulting impairment according to the listings for the affected body system.

 

387.10 Apastic Anemia, Myelofibrosis and Myeloid Metaplasia--

1. A. 

   Hematocrit of 30% or less and blood transfusion at least every 3 months; OR

2. B. 

   Massive splenomegaly with anorexia and marked impairment of general health.

    

387.11 Acute Leukemias --With appropriate findings on peripheral blood smear or bone marrow examination.

 

387.12 Chronic Leukemias --With:

1. A. 

   Hematocrit of 30% or less and blood transfusion at least every 3 months; OR

2. B. 

   Massive splenomegaly with anorexia and marked impairment of general health.

    

387.13 Lymphomas and Multiple Myeloma-- See neoplastic diseases, §393.

 

387.14 Macroglobulinemia (Diagnosis confirmed by ultracentrifugation or immunoelectrophoresis)--With frequent hemorrhages from body orifices requiring blood transfusion at least every 3 months.

 

387.15 Miliary Tuberculosis--

1. A. 

   Demonstration of tubercle bacilli-- more than 3 months following the onset of disability; OR

2. B. 

   Residual impairment of body systems. Evaluate the resulting impairment according to the listings for the affected body system.

    

387.16 Tuberculous Adenitis--

1. A. 

   Demonstration of tubercle bacilli more than 3 months following the onset of disability; OR

2. B. 

   Other evidence of increasing activity or extent of lesion more than 3 months following onset of disability.

    

388. Skin

Conditions of the skin, including disfiguring scars and repugnant skin disease, will not ordinarily be found in themselves to be totally disabling. Some skin conditions, such as the ulcerations and exzemas associated with severe varicose veins, or the disfiguring and repugnant skin lesions of leprosy, are significant as manifestations of the underlying disabling 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 on the basis of the Listing of Impairments for the Musculoskeletal System (§381 ff.).

 

388.01 Category of Impairments, the Skin--

 

Leprosy --As active disease, consider as “under a disability” for 1 year following discharge from the hospital.

Thereafter, evaluate residuals such as blindness, loss of use of hands, etc., according to the listing for the affected body system.

 

388.03 Exfoliative Dermatitis, primary type and generalised --In grave and protractive types, consider “under a disability.”

 

388.04 Pemphigus --Consider under §388.03.

 

389. Endrocrine System

1. A. 

   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 listed under the appropriate sections. The major complications of endocrine disorders are cardiovascular (§384), psychiatric (§392), genitourinary (§386), hematologic ( §387), and musculoskeletal abnormalities (§381). Hyperfunction or hypofunction of the adenohypophysis does not in itself cause an impairment. The impairment results from subsequent malfunction of the affected target gland, and the impairment should be evaluated according to the listings for the appropriate target gland.

2. B. 

   Diabetes Mellitus --Diabetes mellitus is a chronic disorder of metabolism, characterized by hyperglycemia, glycosuria, polyuria, polyphagia, polydipsia, weakness and weight loss. In most situations, inability to engage will not result, because replacement therapy will adequately control these abnormalities. Degenerative vascular changes may lead to complications and severe impairment. The most commonly occurring disabling sequelae appear in the eyes, heart, peripheral vascular system of the lower extremities, nervous system, and kidneys. For example: recurrent and extensive diabetic changes in the blood vessels of the retina may result in significant interference with visual efficiency. Neurogenic pathology with destruction of a major joint is permanent, irreversible, and nonremediable, with resulting gait impairment. Ambulation may also be significantly impaired with widespread peripheral vascular degeneration in lower extremities. There may be significant renal changes. Myocardial infarction may occur somewhat earlier than otherwise in diabetes mellitus and also has a somewhat less favorable prognosis in the diabetic individual. The course of pulmonary tuberculosis may be altered by the coexistence of the diabetic state.

Adequate medical examinations and accurate measurement of functions are required in order to determine which organs are involved and how these have affected the individual's activites. This basic principle applies whether diabetes exists alone or in combination with other physical and/or mental impairment(s). Evaluation, when the musculoskeletal system is concerned, should be based on the demonstrated remaining capacities of the musculoskeletal system, and vascular changes or neurological changes.

 

389.01 Category of Impairments, Endocrine System

 

389.02 Hyperthyroidism --With:

1. A. 

   Severe exophthalmos; OR

2. B. 

   Evaluate the resulting impairment according to the listings for the affected body system.

    

389.03 Hypothyroidism --Evaluate the resulting impairment according to the listings for the affected body system.

 

389.04 Hyperparathyroidism --With:

1. A. 

   Severe generalized decalcification of bone and elevation of plasma calcium to greater than 11 mg./100 ml.; OR

2. B. 

   Evaluate the resulting impairment according to the listings for the affected body system.

    

389.05 Hypoparathyroidism --With:

1. A. 

   Severe recurrent tetany; OR

2. B. 

   Recurrent generalized convulsion; OR

3. C. 

   Lenticular cataracts (evaluate according to §382 ff.)

    

389.06 Neurohypophyseal Insufficiency (diabetes insipidus)--With marked polyuria and persistent urine specific gravity below 1.005 and dehydration.

 

389.07 Hyperfunction of the Adrenal Cortex --Evaluate the resulting impairment according to the listings under the affected body system.

 

389.08 Adrenal Cortical Insufficiency (Addison's disease)--With recurrent episodes of circulatory collapse manifested by severe hypotensive episodes.

 

389.09 Diabetes Mellitus

1. A. 

   When diabetes mellitus exists with other physical or mental impairments, evaluate according to the listings for the appropriate body systems.

2. B. 

   Diabetes mellitus with one of the following (not covered under existing body system listing):

   1. 1. 

      retinitis proliferans with resultant progressive loss of vision and field restriction centrally or peripherally; OR

   2. 2. 

      retinopathy with rubeosis iridis; OR

   3. 3. 

      Kimmelstiel-Wilson syndrome evidenced by hyperglycemia, retinitis, hypertension, with persistent proteinuria and edema; OR

   4. 4. 

      pyuria persisting despite prescribed therapy, with renal damage and significantly impaired renal function; OR

   5. 5. 

      neurogenic arthritis with flail limb (“Charcot joint”); OR

   6. 6. 

      foot, leg, or thigh amputation due to diabetic necrosis, with evidence of peripheral vascular disease in the remaining or other extremity; OR

   7. 7. 

      neuropathy, evidenced by persistent pain and sensory changes with abnormally reduced deep tendon reflexes; or disturbances of gait with one of these; OR

   8. 8. 

      acidosis occurring at least on an average of once every two months, documented by appropriate flucose and eletrolyte or bicarbonate blood levels.

       

390 The Nervous System

Introduction

Disorders of the nervous system are either neurological or psychiatric, and in some instances a combination of both.

Neurological disorders are covered under §391. They include partial or complete loss of motor ability, abnormal motion such as convulsions, twitching, and tremors, and disturbance of sensory functions such as pain, tingling, and loss of hearing and position sense.

The psychiatric disorders are covered in §392. They include disorders of perception (e.g., hallucinations); disorders of thinking (e.g., delusions, obsessions, suicidal rumination); disorders of affect (e.g., depression, elation); disorders of memory (e.g., amnesia, confabulation); disorders of consciousness (e.g., confusion, dream and fague states, stupor); disorders of intellect; and disorders of psychophysiological function.

 

391. Neurology

1. A. 

   Neurological disturbances have, for the most part, demonstrable lesions in the central nervous system. Evidence required for determiation of disability may be different for various neurological impairments.

2. B. 

   Epilepsy --Epilepsy may be idiopathic, with onset in childhood, adolescence, or young adulthood. In other cases, particularly with onset in later life, it may be symptomatic, i.e., due to a known precipitating cause, such as head injuries, brain tumors, infectious diseases, heavy metal poisoning (e.g., lead, arsenic), or following brain surgery. If possible, epilepsy should be substantiated by an EEG and at least one objective, 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 and establishment of their frequency only if professional observation is not available, The severity of the impairment should be determined according to the frequency, duration, and sequelae of seizures. If the disease is of long duration, residual changes in personality and intellect should also be ascertained and evaluated in conjunction with the epileptic condition.

3. C. 

   Cerebrovascular Accident --The residuals of a cerebrovascular accident after the acute phase (usually 4 months after onset) should be evaluated on the basis of the severity of the impairment of speech, mental (see §392.02), sensory, and motor function. Particularly where impairment of motor function of the extremities is the predominant residual impairment, evaluation should include the consideration of any additional losses of body function due to the disease process. See DISM §322.5 and §384.03.

4. D. 

   Cerebral Arteriosclerosis , with hemiplegic symptoms, pseudobulbar palsy, or with bulbar symptoms, or with parkinsonian symptoms.--Consider on the basis of residuals, referring to impairment of arm, leg, and speech, and severity of any other residuals, such as tremors, etc.

5. E. 

   Brain Tumor --Signs and symptoms are due to increased intracranial pressure and/or neurological deficit at the site of the lesion. Benign tumors can frequently be completely removed without causing significant residual impairment. Malignant tumors can often be only incompletely excised or, if inoperable, may be treated by craniotomy for relief of headache or other signs of intracranial pressure; restoration of the individual's ability to function will then usually be temporary or partial, and the overall prognosis is poor. Occasionally, signs of an organic brain syndrome may develop.

    

391.01 Category of Impairments--Neurology

 

391.02 Epilepsy--without psychiatric impairment

1. A. 

   Major motor seizures (grand mal or psychomotor), occurring more frequently than once a month in spite of prescribed treatment, with verified diurnal episodes (loss of consciousness and convulsive seizure) or nocturnal episodes which show residuals interfering with activity during the day; OR

2. B. 

   Minor motor seizures (petit mal or psychomotor), averaging one or more per week in spite of prescribed treatment, with alteration of awareness or loss of consciousness and with transient post-ictal manifestations of unconventional or antisocial behavior.

    

391.03 Cerebrovascular Accident --With:

1. A. 

   Persistent sensory or motor aphasia resulting in ineffective speech or communication; OR

2. B. 

   Permanent motor or sensory defect or organic brain damage of any degree, in combination with hypertensive vascular disease (§384.03) or hematologic disease (§387A); OR

3. C. 

   Pseudobulbar palsy; OR

4. D. 

   Evaluate on the basis of resultant neurological involvement.

    

391.04 Brain Tumor --Evaluate on the basis of resultant neurological involvement.

 

391.05 (Paralysis Agitans (Parkinson's Disease)--With well developed tremor, rigidity, and impairment of mobility.

 

391.06 Cerebral Palsy --With:

1. A. 

   Mental retardation (I.Q. of 69 or less); OR

2. B. 

   Abnormal behavior patterns, such as destructiveness or emotional instability; OR

3. C. 

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

4. D. 

   Evaluate on the basis of resultant neurological involvement.

    

391.07 Bulbar Palsy--

 

391.08 Spinal Cord Lesions, due to any cause--Evaluate on the basis of resultant neurological involvement.

 

391.09 Multiple Sclerosis, Amyrotrophic Lateral Sclerosis, and Syringomyelia -- Evaluate on the basis of resultant neurological involvement.

 

391.10 Anterior poliomyelitis --With:

1. A. 

   Flexion contractures (of muscles or tissue) around two major joints (excluding elbows); OR

2. B. 

   Bilateral paralysis of muscles of pelvic girdle, with inability to elevate thighs; OR

3. C. 

   Bilateral paralysis of muscles of shoulder girdle, with inability to raise both arms at shoulder to 90 degrees, OR

4. D. 

   Respiratory distress; OR

5. E. 

   Evaluate on the basis of resultant neurological involvement.

    

391.11 Myasthenia Gravis --Evaluate on the basis of resultant neurological involvement.

 

391.12 Muscular Dystrophy --With:

1. A. 

   Waddling or incoordinate gait; OR

2. B. 

   Flexion deformities of both lower extremities; OR

3. C. 

   Weakness or paralysis of muscles of shoulder girdle or of the neck, with inability to raise both arms at shoulder to 90 degrees.

    

391.13 Peripheral Neuropathies --Evaluate on the basis of resultant neurological involvement.

 

391.14 Tabes Dorsalis --Evaluate on the basis of resultant neurological involvement.

 

392. Psychiatry

Introduction --For the purpose of this program, psychiatric disorders will be considered in four group entities: organic brain syndromes, functional disorders, personality disorders, and mental deficiency.

Discusion of Psychiatric Disorders

1. A. 

   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 under our program. They are temporary and reversible conditions with favorable prognosis and no significant residuals. They are short-lived, self-limited, and do not produce “inability to work.” Occasionally, an acute brain syndrome may progress into a chronic brain syndrome.

   Chronic Brain Syndromes result from relatively permanent, 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 mental 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.

   Chronic brain syndromes can be found in connection with and/or may result from:

   1. 1. 

      Intracranial infections (e.g., CNS syphilis, encephalitides).

   2. 2. 

      Repeated and/or prolonged exposure to alcohol, drug, or toxic agents (e.g., Korsakoff's psychosis, lead, arsenic, carbon monoxide).

   3. 3. 

      Trauma producing diffuse and permanent brain damage.

   4. 4. 

      Circulatory disturbance (e.g., cerebral arteriosclerosis, embolism, thrombosis, intracranial hemorrhage).

   5. 5. 

      Convulsive disorders (epilepsy) and intracranial neoplasms.

   6. 6. 

      Metabolic and degenerative disoreders (e.g., pellagra, multiple sclerosis, Alzheimer's and Pick's disease, Huntington's chorea).

2. B. 

   Functional Psychiatric Disorders are disorders of psychogenic origin, without demonstrable structural changes in the brain tissue. Allowed cases involving functional mental impairments should be scheduled for periodic reexaminations as required by §253.

   Psychotic Disorders --Involutional psychotic, manic-depressive, psychotic depressive, schizophrenic and paranoid reactions are characterized by varying degrees of personality disoranization and accompanied by a corresponding degree of inability to maintain contact with reality (e.g., hallucinations, delusions). The capacity for effective work and ability to relate to other people may be temporarily or permanently impaired.

   Nonpsychotic Disorders

   1. 1. 

      Psychophysiologic autonomic and visceral disorders (cardiovascular, gastrointestinal, genitourinary, 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 and to various visceral disorders. If the condition persists, it may lead to demonstrable structural changes (e.g., peptic ulcer, bronchial asthma, colitis, dermatitis).

   2. 2. 

      Psychoneurotic disorders (anxiety reaction, neurotic-depressive reaction, conversion 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 based on deep-seated emotions and conflicts below the level of conscious awareness which pose a profound threat to the psychological integrity of the individual. The classification of psychoneurotc disorders is largely based on the defense mechanism 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 not of a psychoneurotic nature. They are self-limited and the symptoms generally recede when the situational stress diminishes.

3. C. 

   Personality Disorders (Inadequate, schizoid, cyclothymic, paranoid personalities; emotional instability, passive-aggressive and passive-dependent behavior; compulsive personality; antisocial behavior, sexual deviation, addiction; lack of motivation).--These disorders, the result of inherent defects in personality structure, are often characterized by lifelong patterns of inadequate or socially unacceptable behavior with minimal subjective anxiety and little or no sense of distress. In contrast with neuroses and psychoses in which the individual succumbs to environmental stress, an individual with a personality disorder will often make an attempt (not infrequently successful) to alter or influence the environment to conform with his self-centered confort, without motivation for improvement. In our present state of knowledge, the personality structure of these individuals can rarely, if ever, be altered by any form of therapy; however, in some cases, functioning may be improved by prolonged, specialized treatment.

   Personality disorders by themselves are not disabling. On the other hand, individuals with a personality disorder would be found under a disability if there is:

   1. 1. 

      Adequate evidence demonstrating that the patterns of inadequate or socially unacceptable behavior are symptomatic of underlying organic brain syndrome (e.g., post-traumatic or post-encephalitic personality disorders) or functional mental illness (e.g., schizophrenic reaction). The determination of disability is based on the severity of the underlying organic or functional mental illness.

   2. 2. 

      Adequate evidence of organic brain pathology or of medical or surgical pathology as a direct result of socially unacceptable behavior (e.g., Korsorkoff's syndrome, other encephalopathies, cirrhosis of the liver; injuries sustained during antisocial activity). The determination of disability will be based primarily on the severity of the superimposed pathology.

   3. 3. 

      Adequate evidence of a severe psychoneurosis or psychosis. Not included in this category are brief psychotic episodes which occur not infrequently in prisoners in reaction to the environment.

4. D. 

   Mental Deficiency denotes a lifelong disorder characterized by below-average intellectual endowment as measured on standard intelligence tests (IQ) 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.

   1. 1. 

      The degree of impairment due to mental deficiency should be determined primarily on the IQ and the medical report. Intelligence tests should be administered and interpreted by a qualified psychologist or psychiatrist utilizing such examinations as the Wechsler Adult Intelligence Scale (WAIS), the Wechsler Intelligence Scale for Children (WISC), and the revised Stanford-Binet, or (when indicated) performance type tests such as Pintner-Patterson or Grace Arthur, etc. In communities where a qualified psychologist or psychiatrist is not readily available, an intelligence test administered by a VR counselor or a specially trained person associated with the local school system may be accepted, particularly when other findings are also demonstrative of extremely low intellectual capacity. The test should be administered at age 16 or over. An IQ taken at an earlier age may be accepted if the longitudinal evidence demonstrates incapacity of such severity that additional testing would serve no useful purpose.

   2. 2. 

      In cases where the nature of the individual's impairment is such that testing, as described above, is precluded or cannot be obtained, the medical reports should give specific information describing the level of intellectual, social and physical function to support the indication that the individual is incapacitated. 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 lending additional weight to the evidence in the medical report.

   3. 3. 

      In some cases mental deficiency is only part of the impairment. The applicant may also have cerebral palsy, epilepsy, psychosis, etc. If the associated condition is such as to constitute a “disability,” it is unnecessary to secure the IQ.

5. E. 

   Prognosis in Psychiatric Disorders (See §253 for establishing medical reexamination dates).--

   1. 1. 

      The impairment of brain tissue in the chronic organic brain syndromes and mental deficiency generally being irreversible, recovery or remission in these conditions is not the rule.

   2. 2. 

      Mood disorders (manic-depressive reaction, involutional psychotic reaction, psychotic depressive reaction) generally respond well to psychiatric treatment, although relapses may occur.

   3. 3. 

      The prognosis in schizophrenic reactions is generally guarded and depends on factors such as the duration of the illness (acute versus chronic) and the type of reaction (simple, catatonic, hebephrenic, paranoid, etc).

   4. 4. 

      The prognosis is psychoneurosis and psychophysiologic disorders is generally favorable with proper psychiatric treatment.

   5. 5. 

      In personality disorders which are characterized by a lifelong pattern of inadequate or socially unacceptable behavior, motivation for treatment is frequently lacking and changes in the personality structure are not likely to occur. However, functioning may be improved by prolonged, specialized treatment.

6. F. 

   Documentation --The severity of a psychiatric disorder can be evaluated on the basis of:

   1. 1. 

      Physician's report (preferably by a psychiatrist) which include history, objective findings, diagnosis, response to therapy.

   2. 2. 

      Daily Activities--Since severity of impairment is generally in direct proportion to its effect on the individual's daily activities, interests, personal habits, behavior, and the ability to relate to others, such information is very valuable in the adjudicative process. Much of this information is obtainable from a psychiatric social service survey. However, this information may also be obtained from the applicant (R/C), his former employer, physician, clinical psychologist, hospital and court records, social service and welfare agencies.

   3. 3. 

      Psychological Tests--In some cases, psychological tests (for intelligence level, organicity, personality make-up, etc.) may be helpful in differential diagnosis.

   4. 4. 

      Hospital Reports--When the claimant is hospitalized for “mental illness,” it is necessary to obtain a Form OA-D824 or a summary psychiatric report adequately showing history, physical and mental status examination, and other clinical data including diagnosis, therapy, response to treatment, prognosis, and social, industrial and occupational activities while in the hospital.

      It is ordinarily necessary to obtain the record of his course in the hospital and a current medical report from the individual's attending physician, the hospital staff, or other sources. Hospital reports should definitely indicate whether or not the hospitalization has been continuous and, in cases where there is doubt as to the continuity of the hospitalization, development of this point should be undertaken. Experience has demonstrated that many reports fail to mention extended period of trial visit which may have a bearing on the adjudication of the case.

      Release of trial visit is often an indication of improvement. However, some patients are released because they are not particularly dangerous to themselves or others, have reached a point where they are not longer able to benefit from hospital treatment, and instead require supervision (custodial care). Some leave the hospital because they are senile and harmless; others, as a result of insistence by the family. Trial visit then, in and of itself, does not necessarily indicate recovery or that recovery is foreseeable, and requires further development to determine its basis.

      Recurrent hospitalizations are often evidence of a severe impairment. In determining whether a claimant was under a disability, consideration should be given to the length of time lapse between each period of hospitalization, the reasons for hospitalization, the severity of the impairment and response to treatment particularly as reflected in the claimant's adjustment out of the hospital.

      An individual may be receiving institutional care because of the commission of a crime rather than for the impairment or he may be hospitalized because of a personality disorder which may or may not be a manifestation of an underlying functional or orgainic psychiatric illness. In such cases, the determination of disability is based on the severity of the mental disorder and the resulting impairment as evidenced by the clinical findings regardless of the reason for the commitment.

       

392.01 Category of Impairments, Psychiatry

 

392.02 Chronic Organic Brain Syndromes --With severe symptoms such as marked memory defect for recent events, disorientation as to time, place, and person, marked confusion, deterioration of intellectual functioning, liability and shallowness of affect (rapidly fluctuating moods), etc.

 

392.03 Functional Psychotic Disorders

1. A. 

   Mood Disorders (involutional psychotic reaction, manic-depressive reaction, psychotic depressive reaction, psychomotor disturbance, hallucinations (rare), or delusions, resulting in marked constriction of daily activities and interests, deterioration in personal habits, and seriously impaired ability to relate to other people.

2. B. 

   Schizophrenic Disorders (simple, hebephrenic, catatonic, paranoid, chronic undifferentiated, schizoaffective)--With: persistent hallucinations, delusions, autistic or other regressive behavior, inappropriateness of affect, blocking, illogical associations of ideas, and psychomotor disturbances resulting in marked constriction of daily activities, and interests, deterioration in personal habits, and seriously impaired ability to relate to other people.

3. C. 

   Paranoid Reactions (paranoid states and paranoia).--With: persistent delusions, generallypersecutory or grandiose in character resulting in marked constriction of daily activities and interests, deterioration in personal habits, and seriously impaired ability to relate to other people.

    

392.04 Functional Non-Psychotic Disorders

1. A. 

   Psychophysiologic Autonomic and Visceral Disorders --With: demonstrable structural changes and persistent preoccupation with symptoms (discomfort, malfunctioning) resulting in marked constriction of daily activities and interests, deterioration in personal habits, and seriously impaired ability to relate to other people.

2. B. 

   Psychoneurotic Disorders --With:

   1. 1. 

      severe and persistent preoccupation with symptoms of a somatic (discomfort, malfunctioning, etc.) and/or mental (protective rituals, phobias, etc.) nature, resulting in marked constriction of daily activities and interests, deterioration in personal habits, and seriously impaired ability to relate to other people; OR

   2. 2. 

      persistent disruption in the useful function of a limb (with resulting observable trophic changes), vision, speech, or hearing; OR

   3. 3. 

      frequent episodes of amnesia, stupor, fugue, or depersonalization.

       

392.05 Mental Deficiency --With:

1. A. 

   Severe mental and social incapacity (verified by objective sources as specified in §392D) evidenced by marked dependence upon others for personal needs (e.g., bathing, washing, dressing, etc.); lack of capacity to understand the spoken word, to avoid physical danger (fire, cars, etc,) without close supervison, follow simple directions, read and write, perform simple calculations; OR

2. B. 

   IQ of 49 or less (mental age of 7 or less); OR

3. C. 

   IQ of 50 to 69, inclusive (mental age of 8 through 11 years) with such additional factors as emotional instability or inability to function without close supervision.

    

393. Neopastic Disease--Malignant

1. A. 

   Definition --A malignant neoplastic disease is one in which cells become autonomous. Their rate of growth and reproduction increases. They may spread from their original location to adjacent and distant organs in the same and other body cavities. They usually alter the normal physiological mechanisms to such an extent that severe disability may follow.

2. B. 

   Establishing the Diagnosis --The diagnosis is needed to help determine (1) whether the specific disease for which applicant claims disability is actually present, (2) whether it will meet the 12-month duration requirement or end in death; (3) whether it produced disability so severe as to prevent the applicant from engaging in substantial gainful activity.

   The diagnosis should be established by adequate evidence which in most instances would include histopathological study of a biopsy. The biopsy helps define cell type, organs involved, possibility of metastasis, and possibility of producing disability effects. Gross pathological evidence should be used only under unusual circumstances; these circumstances limited largely to unavailability of diagnostic facilities, in which case the clinical evidence should be such that a reviewing physician, given only findings, could arrive at an independent diagnosis.

3. C. 

   Evaluation of Impairment --The disabling effects of malignant neoplastic disease are varied. The end result is inability to cerebrate, oxygenate, locomote, manipulate, etc. There are a few malignant diseases in which “disability” is nearly always present or shortly will be by virtue of their location in vital organs, e.g., liver, brain, heart.

   Studies on employment of cancer patients following surgery and/or irradiation have shown that many patients are physically able to resume their usual occupations or activites. Physical changes in body form and function do not unduly interfere with resumption of work or other activities after a short period of convalescence where the disease is confined to the primary site (with certain exceptions noted above) or involves local lymph nodes which are completely resected at the time of surgery.

   The presence of distant metastasis may be considered severe enough to prevent substantial gainful activity in that severe impairment is present or may be expected to soon follow. Evidence of metastasis may be established by biopsy or appropriate clinical precedures where the primary lesion has been confirmed by biopsy.

    

393.01 Category of Impairments, Neoplastic Disease--Malignant

 

393.02 Not amenable to curative therapy

1. A. 

   Inoperability

   1. 1. 

      When the contiguous spread of the disease is so extensive as to prohibit attempts at curative surgery procedure.

   2. 2. 

      Distant metastasis; proven by biopsy or demonstrated by appropriate clinical procedures once the primary lesion has been confirmed by biopsy.

   3. 3. 

      When the primary site in and of itself usually precludes adequate surgical therapy; based on brain, liver, head of pancreas, upper 2/3 of esophagus.

   4. 4. 

      Other conditions of inoperability

2. B. 

   Not curable by prescribed therapy (e.g., irradiation, chemotherapy).

    

393.03 Severe post-therapeutic residuals

For example: Laryngectomy with loss of speech (see §383.11) or resection of tongue with loss of speech; or pneumonectomy with resultant dyspnea on slight exertion; or severe post-irradiational complication; or colostomy. (See §385.11)

 

393.04 Lymphoma and allied disorders (Hodgkin's disease, lymphosarcoma, etc.)

1. A. 

   Generalized--Confirmed by biopsy; and systemic; and progressive and severe consitutional symptoms.

2. B. 

   Localized--Evaluate on residuals.