Basic (07-19)

DI 24583.010 Determining Medical Equivalence for Mental Impairments

A. How do we determine medical equivalence for mental impairment(s)?

An impairment(s) is medically equivalent to a listed impairment in the Listing of Impairments (listings) if it is at least equal in severity and duration to the criteria of any listed impairment. We evaluate medically determinable mental impairment(s) using the mental disorders listings. For the general rules for finding medical equivalence, see DI 24508.010. For rules on finding medical equivalence in children, see DI 25220.010. For the adult mental disorders listings, see DI 34001.032. For the childhood mental disorders listings, see DI 34005.112.

The mental impairment identified by the paragraph A criteria of the mental disorders listings must cause the functional limitations assessed by the paragraph B or paragraph C criteria of the mental disorders listings. Many people have multiple co-occurring mental impairments. Sometimes it is not possible to determine whether the mental impairment identified by the paragraph A criteria is the cause of the functional limitations due to multiple co-occurring mental impairments. In those cases, consider whether the combination of mental impairments medically equals a mental disorders listing. For more information, see DI 24583.010A.3.

There are three ways to find medical equivalence. We consider whether the person has:

  • A listed mental impairment (that is, a mental impairment in a listed mental disorders category);

  • An unlisted mental impairment (that is, a mental impairment that is not part of a listed mental disorders category); or

  • A combination of mental impairments.

1. Listed mental impairments

If a person has a mental impairment that is evaluated under one of the mental disorders listings, but the findings related to the impairment do not satisfy the paragraph A criteria (for every listing except listing 12.05), determine whether the clinical findings are at least of equal medical significance to the listed paragraph A criteria. The mental impairment must also impose limitations as described in paragraph B (of every listing except 12.05) or paragraph C (for listings 12.02, 12.03, 12.04, 12.06, and 12.15), as appropriate. There are not findings that can be substituted for the paragraph B or paragraph C criteria. When the paragraph B or paragraph C criteria are not satisfied, the person does not have a mental impairment that meets or medically equals a listed mental impairment.

NOTE: For special instructions regarding listing 12.05, see DI 24583.010B.

2. Unlisted mental impairments

There are not mental disorders listings for all mental impairments. If a person’s mental impairment is not part of a listed mental disorders category, compare the clinical findings of the unlisted mental impairment to the paragraph A criteria in a closely analogous mental disorders listing (for every listing except 12.05) and determine whether the clinical findings are at least of equal medical significance to the analogous listing. The mental impairment must also impose limitations as described in paragraph B (of every listing except 12.05) or paragraph C (for listings 12.02, 12.03, 12.04, 12.06, and 12.15), as appropriate.

EXAMPLE: Dissociative identity disorder is an unlisted mental impairment that may sometimes reach listing level severity under one or more listings. Dissociative identity disorder could be evaluated under listing 12.04, Depressive, bipolar, and related disorders based on the similarities in diagnostic features. However, based on the individual presentation of signs and symptoms in a given person, evaluation under a different listing may also be appropriate.

NOTE: For special instructions regarding listing 12.05, see DI 24583.010B.

3. Combination of impairments

If a person has a combination of mental impairments, his or her condition may medically equal a mental disorders listing in three ways, as described below. The combination of mental impairments must also impose restrictions as described in paragraph B (of every listing except 12.05) or paragraph C (for listings 12.02, 12.03, 12.04, 12.06, and 12.15), as appropriate.

NOTE: For special instructions regarding listing 12.05, see DI 24583.010B.

NOTE: It is generally not appropriate to medically equal a mental disorders listing using a combination of physical and mental impairments. However, in cases where the mental effects of multiple physical and mental disorders cannot be separated, it may be appropriate to consider medical equivalence using a combination of physical and mental impairments. For example, consider a case with a claimant with a neurological disorder causing physical and mental limitations that do not meet the criteria of any neurological disorders listing, along with a coexisting mental impairment, the effects of which cannot be separated from those of the neurological disorder. In such a situation, it may be appropriate to medically equal a mental disorders listing.

a. Medical equivalence to the paragraph A criteria through a combination of mental impairments

Medical equivalence may be appropriate when the paragraph A criteria of a mental disorders listing (for every listing except 12.05) are satisfied through a combination of mental impairments. These cases will always involve limitations resulting from a combination of mental impairments to satisfy the paragraph B criteria or paragraph C criteria. There are not findings that can be substituted for the paragraph B or paragraph C criteria. When the paragraph B or paragraph C criteria are not satisfied, the person does not have a mental impairment that meets or medically equals a listed mental impairment.

EXAMPLE: The person has generalized anxiety disorder and posttraumatic stress disorder that do not individually satisfy the paragraph A criteria of either listing 12.06 or 12.15. If the combination of generalized anxiety disorder and posttraumatic stress disorder result in clinical findings that are at least of equal medical significance to the listed paragraph A criteria, then a finding of medical equivalence may be appropriate.

b. Medical equivalence to the paragraph B criteria through a combination of mental impairments

In many cases involving multiple mental impairments, it is not possible to identify which mental impairment causes the functional limitations that satisfy the paragraph B criteria. In these cases, medical equivalence may be appropriate because the combination of mental impairments results in extreme limitation of one, or marked limitation of two, of the four areas of mental functioning in the paragraph B criteria (for every listing except 12.05, see DI 24583.010B.3).

EXAMPLE: The person has generalized anxiety disorder and posttraumatic stress disorder that individually satisfy the paragraph A criteria of listings 12.06 and 12.15, respectively. The person also has marked limitations in the paragraph B criteria for interact with others and concentrate, persist, or maintain pace. However, it is not clear from the medical evidence whether the functional limitations result from the generalized anxiety disorder, the posttraumatic stress disorder, or the combination of the two mental impairments. A finding of medical equivalence would be appropriate.

c. Medical equivalence to the paragraph C criteria through a combination of mental impairments

A finding of medical equivalence for the paragraph C criteria is appropriate only in cases that involve a combination of mental impairments that are all evaluated under listings that contain paragraph C criteria. Do not find medical equivalence when one of the mental impairments is evaluated under a listing that does not contain paragraph C criteria.

EXAMPLE: The person has schizoaffective disorder and depressive disorder that individually satisfy the paragraph A criteria of listings 12.03 and 12.04, respectively. The person has only mild or moderate limitations in each of the paragraph B criteria. If the person’s combination of depressive disorder and schizoaffective disorder satisfy the requirements of the paragraph C criteria, a finding of medical equivalence may be appropriate because both listings 12.03 and 12.04 contain paragraph C criteria.

EXAMPLE: The person has bipolar disorder and borderline personality disorder that individually satisfy the paragraph A criteria of listings 12.04 and 12.08. The person has only mild or moderate limitations in each of the paragraph B criteria. Even if the person’s combination of mental impairments satisfy the requirements of the paragraph C criteria of listing 12.04, do not find medical equivalence because listing 12.08 does not contain paragraph C criteria.

B. How do we determine medical equivalence for intellectual disorder under listing 12.05?

Listing 12.05 is used to evaluate intellectual disorder and has two paragraphs, A and B. Each paragraph contains the three elements of the medical definition of intellectual disability – significant deficits in general intellectual functioning, significant deficits in adaptive functioning, and evidence that the disorder began during the developmental period. A person’s impairment meets the listing when all of the criteria of either paragraph are satisfied. Generally, it is not possible to find that an intellectual disorder medically equals listing 12.05 except in certain limited circumstances described in DI 24583.010B.2.b and DI 24583.010B.3.

1. Medical equivalence for 12.05A

Do not find that an impairment medically equals 12.05A. There are no clinical findings at least of equal medical significance to an inability to participate in standardized tests of intellectual functioning, dependence upon others for personal needs, or onset during the developmental period.

2. Medical equivalence for assessing significantly subaverage general intellectual functioning under 12.05B

a. Intelligence quotient (IQ) scores

Do not find that other clinical findings are at least of equal medical significance to the IQ scores specified under 12.05B.1. Only consider a person’s obtained IQ scores for 12.05B.1. Do not raise or lower an IQ score or consider IQ scores that are slightly above or below the criteria in 12.05B.1.a or 12.05B.1.b to find medical equivalence. The 12.05B.1.b criterion for significantly subaverage general intellectual functioning already accounts for the scenario involving a person with intellectual disorder whose obtained full scale IQ score is slightly above 70. If the record contains obtained IQ scores that do not satisfy the IQ score criteria for 12.05B.1 but the criteria in 12.05B.2 are satisfied, consider whether the impairment meets or medically equals listing 12.11 for neurodevelopmental disorders or 12.02 for neurocognitive disorders.

b. Nonverbal intelligence tests

Many nonverbal intelligence tests will not meet our requirements for standardized tests of general intelligence found in section 12.00H of the mental disorders listings. In cases where a nonverbal intelligence test is the only way to accurately measure a person’s intellectual functioning, medical equivalence may be appropriate. For more information about using nonverbal intelligence tests, see DI 24583.055I.3.

3. Medical equivalence for assessing significant deficits in adaptive functioning under listing 12.05B

In most cases involving intellectual disorder in combination with other impairments, it is not possible to medically equal the criteria in 12.05B.2 because the functional limitations must result from intellectual disorder. The criteria in 12.05B.2, which are the paragraph B criteria in the other mental disorders listings, are used to assess the intellectual disorder requirement for significant deficits in adaptive functioning. These deficits must be present before age 22. When a case involves intellectual disorder in combination with another impairment that arose after age 22 and you cannot differentiate which impairment affects the rating of the paragraph B criteria, you cannot establish that deficits in adaptive functioning were present before age 22.

Instead, consider whether the impairment meets or medically equals 12.11 for neurodevelopmental disorders or 12.02 for neurocognitive disorders, rather than whether the impairment medically equals listing 12.05. In limited circumstances, medical equivalence may be appropriate for cases involving a combination of intellectual disorder and another mental disorder that began prior to attainment of age 22, such as autism spectrum disorder.

4. Medical equivalence for assessing whether the intellectual disorder began during the developmental period

Do not make a finding of medical equivalence when considering the requirement that the intellectual disorder began prior to the attainment of age 22. If the person’s cognitive impairment satisfies the requirements in 12.05B.1 and 12.05B.2 but there is no evidence supporting the conclusion the disorder began prior to the attainment of age 22, consider whether the impairment meets or medically equals 12.11 for neurodevelopmental disorders or 12.02 for neurocognitive disorders, rather than whether the impairment medically equals listing 12.05.

NOTE: We do not require evidence that existed or was recorded prior to when the person attained age 22. We only need evidence that is consistent with the conclusion the disorder began prior to age 22. For more information about this criterion, see DI 34001.032 (12.00H.4 of the adult mental disorders listings).

C. How do we document medical equivalence determinations?

We evaluate mental impairments using the Psychiatric Review Technique (PRT). We document the application of the PRT on a standard document. For more information about the PRT and the standard document, see DI 24583.005.

On the standard document, describe the pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment. Document the rationale for the finding of medical equivalence, including which clinical findings are at least of equal medical significance to the listed requirements. Include the following types of information, as appropriate:

  • Which finding was not exhibited or was not as severe as specified in the listing?

  • What other findings were at least of equal medical significance?

  • Which mental impairment is an unlisted impairment, and which listing is the analogous listing?

  • What combination of mental impairments does the person have, and how is that combination of at least equal medical significance?

NOTE: These are only examples of information that might be included in an acceptable medical equivalence rationale. The actual rationale used to document the finding of medical equivalence must reflect the specific circumstances of the case.

D. References

  • DI 24508.010 Impairment or Combination of Impairments Equaling a Listing – Medical Equivalence

  • DI 24583.005 Evaluating Mental Impairments Using the Psychiatric Review Technique (PRT)

  • DI 24583.055 Using Intelligence Tests to Evaluate Cognitive Disorders, Including Intellectual Disorder

  • DI 34001.032 Mental Disorders (Listing of Impairments – Adult Listings (Part A))


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DI 24583.010 - Determining Medical Equivalence for Mental Impairments - 07/19/2019
Batch run: 07/25/2019
Rev:07/19/2019