TN 23 (09-20)

DI 22510.049 Pediatric Consultative Examination (CE) Report Content Guidelines for Cancer

Use the following guidelines to provide the minimum content in a CE report for a child disability case. Each Disability Determination Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for pediatric cancer

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines in DI 22510.035. For additional CE policy in a child’s case, also see DI 25205.015.

B. Report content specific to pediatric cancer

The CE provider will use the specific requirements below to complete the CE report specific to cancer.

1. Current medical history

The CE provider will describe and discuss as appropriate:

  1. a. 

    Fatigue, malaise, and/or affected organ systems;

  2. b. 

    Type of therapy received or planned, including prescribed medications and their side effects (for each cancer condition if more than one). If multimodal therapy, dates each therapy was completed/scheduled and performed by which physician;

  3. c. 

    Effects of any post-therapeutic residuals;

  4. d. 

    Planned treatment;

  5. e. 

    Weight loss;

  6. f. 

    Prognosis, if available; and

  7. g. 

    Dates and results of relevant diagnostic procedures, such as biopsy or tissue pathologic examination and imaging studies, as these results relate to information on cancer stage, when possible.

2. Physical examination

The CE provider will describe and discuss as appropriate:

  1. a. 

    Review of any biopsy or tissue pathologic examination;

  2. b. 

    Imaging studies; and

  3. c. 

    Other body systems affected by adverse effects of treatment.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510049
DI 22510.049 - Pediatric Consultative Examination (CE) Report Content Guidelines for Cancer - 01/23/1996
Batch run: 09/25/2020
Rev:01/23/1996