Work incentive experiments and rehabilitation demonstration projects in the disability program.

[Title 20 CFR 404.1599]
[Code of Federal Regulations (annual edition) - April 1, 1996 Edition]
[Title 20 - EMPLOYEES' BENEFITS]
[Chapter III - SOCIAL SECURITY ADMINISTRATION]
[Part 404 - FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- )]
[Subpart P - Determining Disability and Blindness]
[Sec. 404.1599 - Work incentive experiments and rehabilitation demonstration projects in the disability program.]
[From the U.S. Government Publishing Office]

20
EMPLOYEES' BENEFITS
2
1996-04-01
1996-04-01
false
Work incentive experiments and rehabilitation demonstration projects in the disability program.
404.1599
Sec. 404.1599

EMPLOYEES' BENEFITS
SOCIAL SECURITY ADMINISTRATION
FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- )
Determining Disability and Blindness

Sec. 404.1599 Work incentive experiments and rehabilitation demonstration projects in the disability program.

(a) Authority and purpose. Section 505(a) of the Social Security
Disability Amendments of 1980, Pub. L. 96-265, directs the Secretary to
develop and conduct experiments and demonstration projects designed to
provide more cost-effective ways of encouraging disabled beneficiaries
to return to work and leave benefit rolls. These experiments and
demonstration projects will test the advantages and disadvantages of
altering certain limitations and conditions that apply to title II
disabled beneficiaries. The objective of all work incentive experiments
or rehabilitation demonstrations is to determine whether the alternative
requirements will save Trust Fund monies or otherwise improve the
administration of the disability program established under title II of
the Act.
(b) Altering benefit requirements, limitations or conditions.
Notwithstanding any other provision of this part, the Secretary may
waive compliance with the entitlement and payment requirements for
disabled beneficiaries to carry our experiments and demonstration
projects in the title II disability program. The projects involve
altering certain limitations and conditions that

[[Page 387]]

currently apply to applicants and beneficiaries to test their effect on
the program.
(c) Applicability and scope--(1) Participants and nonparticipants.
If you are selected to participate in an experiment or demonstration
project, we may temporarily set aside one or more of the current benefit
entitlement or payment requirements, limitations or conditions and apply
alternative provisions to you. We may also modify current methods of
administering the Act as part of a project and apply alternative
procedures or policies to you. The alternative provisions or methods of
administration used in the projects will not disadvantage you in
contrast to current provisions, procedures or policies. If you are not
selected to participate in the experiments or demonstration projects (or
if you are placed in a control group which is not subject to alternative
requirements and methods) we will continue to apply to you the current
benefit entitlement and payment requirements, limitations and conditions
and methods of administration in the title II disability program.
(2) Alternative provisions or methods of administration. The
alternative provisions or methods of administration that apply to you in
an experiment or demonstration project may include (but are not limited
to) one or more of the following:
(i) Reducing your benefits (instead of not paying) on the basis of
the amount of your earnings in excess of the SGA amount;
(ii) Extending your benefit eligibility period that follows 9 months
of trial work, perhaps coupled with benefit reductions related to your
earnings;
(iii) Extending your Medicare benefits if you are severely impaired
and return to work even though you may not be entitled to monthly cash
benefits;
(iv) Altering the 24-month waiting period for Medicare entitlement;
and
(v) Stimulating new forms of rehabilitation.
(d) Selection of participants. We will select a probability sample
of participants for the work incentive experiments and demonstration
projects from newly awarded beneficiaries who meet certain pre-selection
criteria (for example, individuals who are likely to be able to do
substantial work despite continuing severe impairments). These criteria
are designed to provide larger subsamples of beneficiaries who are not
likely either to recover medically or die. Participants may also be
selected from persons who have been receiving DI benefits for 6 months
or more at the time of selection.
(e) Duration of experiments and demonstration projects. A notice
describing each experiment or demonstration project will be published in
the Federal Register before each experiment or project is placed in
operation. The work incentive experiments and rehabilitation
demonstrations will be activated in 1982. A final report on the results
of the experiments and projects is to be completed and transmitted to
Congress by June 9, 1993. However, the authority for the experiments and
demonstration projects will not terminate at that time. Some of the
alternative provisions or methods of administration may continue to
apply to participants in an experiment or demonstration project beyond
that date in order to assure the validity of the research. Each
experiment and demonstration project will have a termination date (up to
10 years from the start of the experiment or demonstration project).

[48 FR 7575, Feb. 23, 1983, as amended at 52 FR 37605, Oct. 8, 1987; 55
FR 51687, Dec. 17, 1990]
Pt. 404, Subpt. P, App. 1

Appendix 1 to Subpart P--Listing of Impairments

The body system listings in parts A and B of the Listing of
Impairments will no longer be effective on the following dates unless
extended by the Commissioner or revised and promulgated again.
1. Growth Impairment (100.00): December 6, 1996.
2. Musculoskeletal System (1.00 and 101.00): June 6, 1996.
3. Special Senses and Speech (2.00 and 102.00): December 4, 1998.
4. Respiratory System (3.00 and 103.00): October 7, 2000.
5. Cardiovascular System (4.00 and 104.00): February 10, 1998.
6. Digestive System (5.00 and 105.00): December 5, 1997.
7. Genito-Urinary System (6.00 and 106.00): December 5, 1997.
8. Hemic and Lymphatic System (7.00 and 107.00): June 6, 1997.

[[Page 388]]

9. Skin (8.00): June 6, 1997.
10. Endocrine System and Obesity (9.00) and Endocrine System
(109.00): June 6, 1997.
11. Multiple Body Systems (110.00): July 2, 1998.
12. Neurological (11.00 and 111.00): June 5, 1998.
13. Mental Disorders (12.00): August 28, 1997.
14. Mental Disorders (112.00): June 12, 1997.
15. Neoplastic Diseases, Malignant (13.00 and 113.00): June 6, 1997.
16. Immune System (14.00 and 114.00): July 2, 1998.

Part A

Criteria applicable to individuals age 18 and over and to children
under age 18 where criteria are appropriate.
Sec.
1.00 Musculoskeletal System.
2.00 Special Senses and Speech.
3.00 Respiratory System.
4.00 Cardiovascular System.
5.00 Digestive System.
6.00 Genito-Urinary System.
7.00 Hemic and Lymphatic System.
8.00 Skin.
9.00 Endocrine System and Obesity.
10.00 [Reserved]
11.00 Neurological.
12.00 Mental Disorders.
13.00 Neoplastic Diseases, Malignant.
14.00 Immune System.

1.00 Musculoskeletal System

A. Loss of function may be due to amputation or deformity. Pain may
be an important factor in causing functional loss, but it must be
associated with relevant abnormal signs or laboratory findings.
Evaluations of musculoskeletal impairments should be supported where
applicable by detailed descriptions of the joints, including ranges of
motion, condition of the musculature, sensory or reflex changes,
circulatory deficits, and X-ray abnormalities.
B. Disorders of the spine, associated with vertebrogenic disorders
as in 1.05C, result in impairment because of distortion of the bony and
ligamentous architecture of the spine or impingement of a herniated
nucleus pulposus or bulging annulus on a nerve root. Impairment caused
by such abnormalities usually improves with time or responds to
treatment. Appropriate abnormal physical findings must be shown to
persist on repeated examinations despite therapy for a reasonable
presumption to be made that severe impairment will last for a continuous
period of 12 months. This may occur in cases with unsuccessful prior
surgical treatment.
Evaluation of the impairment caused by disorders of the spine
requires that a clinical diagnosis of the entity to be evaluated first
must be established on the basis of adequate history, physical
examination, and roentgenograms. The specific findings stated in 1.05C
represent the level required for that impairment; these findings, by
themselves, are not intended to represent the basis for establishing the
clinical diagnosis. Furthermore, while neurological examination findings
are required, they are not to be interpreted as a basis for evaluating
the magnitude of any neurological impairment. Neurological impairments
are to be evaluated under 11.00-11.19.
The history must include a detailed description of the character,
location, and radiation of pain; mechanical factors which incite and
relieve pain; prescribed treatment, including type, dose, and frequency
of analgesic; and typical daily activities. Care must be taken to
ascertain that the reported examination findings are consistent with the
individual's daily activities.
There must be a detailed description of the orthopedic and
neurologic examination findings. The findings should include a
description of gait, limitation of movement of the spine given
quantitatively in degrees from the vertical position, motor and sensory
abnormalities, muscle spasm, and deep tendon reflexes. Observations of
the individual during the examination should be reported; e.g., how he
or she gets on and off the examining table. Inability to walk on heels
or toes, to squat, or to arise from a squatting position, where
appropriate, may be considered evidence of significant motor loss.
However, a report of atrophy is not acceptable as evidence of
significant motor loss without circumferential measurements of both
thighs and lower legs (or upper or lower arms) at a stated point above
and below the knee or elbow given in inches or centimeters. A specific
description of atrophy of hand muscles is acceptable without
measurements of atrophy but should include measurements of grip
strength.
These physical examination findings must be determined on the basis
of objective observations during the examination and not simply a report
of the individual's allegation, e.g., he says his leg is weak, numb,
etc. Alternative testing methods should be used to verify the
objectivity of the abnormal findings, e.g., a seated straight-leg
raising test in addition to a supine straight-leg raising test. Since
abnormal findings may be intermittent, their continuous presence over a
period of time must be established by a record of ongoing treatment.
Neurological abnormalities may not completely subside after surgical or
nonsurgical treatment, or with the passage of time. Residual
neurological abnormalities, which persist after it has been determined
clinically or by direct surgical or other observation that the ongoing
or progressive condition is no longer present, cannot be considered to
satisfy the required findings in 1.05C.

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Where surgical procedures have been performed, documentation should
include a copy of the operative note and available pathology reports.
Electrodiagnostic procedures and myelography may be useful in
establishing the clinical diagnosis, but do not constitute alternative
criteria to the requirements in 1.05C.
C. After maximum benefit from surgical therapy has been achieved in
situations involving fractures of an upper extremity (see 1.12) or soft
tissue injuries of a lower or upper extremity (see 1.13), i.e., there
have been no significant changes in physical findings or X-ray findings
for any 6-month period after the last definitive surgical procedure,
evaluation should be made on the basis of demonstrable residuals.
D. Major joints as used herein refer to hip, knee, ankle, shoulder,
elbow, or wrist and hand. (Wrist and hand are considered together as one
major joint.)
E. The measurements of joint motion are based on the techniques
described in the ``Joint Motion Method of Measuring and Recording,''
published by the American Academy of Orthopedic Surgeons in 1965, or the
``Guides to the Evaluation of Permanent Impairment--The Extremities and
Back'' (Chapter I); American Medical Association, 1971.
1.01 Category of Impairments, Musculoskeletal
1.02 Active rheumatoid arthritis and other inflammatory arthritis.
With both A and B.
A. History of persistent joint pain, swelling, and tenderness
involving multiple major joints (see 1.00D) and with signs of joint
inflammation (swelling and tenderness) on current physical examination
despite prescribed therapy for at least 3 months, resulting in
significant restriction of function of the affected joints, and clinical
activity expected to last at least 12 months; and
B. Corroboration of diagnosis at some point in time by either.
1. Positive serologic test for rheumatoid factor; or
2. Antinuclear antibodies; or
3. Elevated sedimentation rate; or
4. Characteristic histologic changes in biopsy of synovial membrane
or subcutaneous nodule (obtained independent of Social Security
disability evaluation).
1.03 Arthritis of a major weight-bearing joint (due to any cause):
With history of persistent joint pain and stiffness with signs of
marked limitation of motion or abnormal motion of the affected joint on
current physical examination. With:
A. Gross anatomical deformity of hip or knee (e.g, subluxation,
contracture, bony or fibrous ankylosis, instability) supported by X-ray
evidence of either significant joint space narrowing or significant bony
destruction and markedly limiting ability to walk and stand; or
B. Reconstructive surgery or surgical arthrodesis of a major weight-
bearing joint and return to full weight-bearing status did not occur, or
is not expected to occur, within 12 months of onset.
1.04 Arthritis of one major joint in each of the upper extremities
(due to any cause):
With history of persistent joint pain and stiffness, signs of marked
limitation of motion of the affected joints on current physical
examination, and X-ray evidence of either significant joint space
narrowing or significant bony destruction. With:
A. Abduction and forward flexion (elevation) of both arms at the
shoulders, including scapular motion, restricted to less than 90
degrees; or
B. Gross anatomical deformity (e.g., subluxation, contracture, bony
or fibrous ankylosis, instability, ulnar deviation) and enlargement or
effusion of the affected joints.
1.05 Disorders of the spine:
A. Arthritis manifested by ankylosis or fixation of the cervical or
dorsolumbar spine at 30 deg. or more of flexion measured from the
neutral postion, with X-ray evidence of:
1. Calcification of the anterior and lateral ligaments; or
2. Bilateral ankylosis of the sacroiliac joints with abnormal
apophyseal articulations; or
B. Osteoporosis, generalized (established by X-ray) manifested by
pain and limitation of back motion and paravertebral muscle spasm with
X-ray evidence of either:
1. Compression fracture of a vertebral body with loss of at least 50
percent of the estimated height of the vertebral body prior to the
compression fracture, with no intervening direct traumatic episode; or
2. Multiple fractures of vertebrae with no intervening direct
traumatic episode; or
C. Other vertebrogenic disorders (e.g., herniated nucleus puplosus,
spinal stenosis) with the following persisting for at least 3 months
despite prescribed therapy and expected to last 12 months. With both 1
and 2:
1. Pain, muscle spasm, and significant limitation of motion in the
spine; and
2. Appropriate radicular distribution of significant motor loss with
muscle weakness and sensory and reflex loss.
1.08 Osteomyelitis or septic arthritis (established by X-ray):
A. Located in the pelvis, vertebra, femur, tibia, or a major joint
of an upper or lower extremity, with persistent activity or occurrence
of at least two episodes of acute activity within a 5-month period prior
to adjudication, manifested by local inflammatory, and systemic signs
and laboratory findings (e.g., heat, redness, swelling, leucocytosis, or
increased sedimentation rate) and expected to last at least 12 months
despite prescribed therapy; or

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B. Multiple localizations and systemic manifestations as in A above.
1.09 Amputation or anatomical deformity of (i.e., loss of major
function due to degenerative changes associated with vascular or
neurological deficits, traumatic loss of muscle mass or tendons and X-
ray evidence of bony ankylosis at an unfavorable angle, joint
subluxation or instability):
A. Both hands; or
B. Both feet; or
C. One hand and one foot.
1.10 Amputation of one lower extremity (at or above the tarsal
region):
A. Hemipelvectomy or hip disarticulation; or
B. Amputation at or above the tarsal region due to peripheral
vascular disease or diabetes mellitus; or
C. Inability to use a prosthesis effectively, without obligatory
assistive devices, due to one of the following:
1. Vascular disease; or
2. Neurological complications (e.g., loss of position sense); or
3. Stump too short or stump complications persistent, or are
expected to persist, for at least 12 months from onset; or
4. Disorder of contralateral lower extremity which markedly limits
ability to walk and stand.
1.11 Fracture of the femur, tibia, tarsal bone of pelvis with solid
union not evident on X-ray and not clinically solid, when such
determination is feasible, and return to full weight-bearing status did
not occur or is not expected to occur within 12 months of onset.
1.12 Fractures of an upper extremity with non-union of a fracture
of the shaft of the humerus, radius, or ulna under continuing surgical
management directed toward restoration of functional use of the
extremity and such function was not restored or expected to be restored
within 12 months after onset.
1.13 Soft tissue injuries of an upper or lower extremity requiring
a series of staged surgical procedures within 12 months after onset for
salvage and/or restoration of major function of the extremity, and such
major function was not restored or expected to be restored within 12
months after onset.

2.00 Special Senses and Speech

A. Ophthalmology
1. Causes of impairment. Diseases or injury of the eyes may produce
loss of central or peripheral vision. Loss of central vision results in
inability to distinguish detail and prevents reading and fine work. Loss
of peripheral vision restricts the ability of an individual to move
about freely. The extent of impairment of sight should be determined by
visual testing.
2. Central visual acuity. A loss of central visual acuity may be
caused by impaired distant and/or near vision. However, for an
individual to meet the level of severity described in 2.02 and 2.04,
only the remaining central visual acuity for distance of the better eye
with best correction based on the Snellen test chart measurement may be
used. Correction obtained by special visual aids (e.g., contact lenses)
will be considered if the individual has the ability to wear such aids.
3. Field of vision. Impairment of peripheral vision may result if
there is contraction of the visual fields. The contraction may be either
symmetrical or irregular. The extent of the remaining peripheral visual
field will be determined by usual perimetric methods at a distance of
330 mm. under illumination of not less than 7-foot candles. For the
phakic eye (the eye with a lens), a 3 mm. white disc target will be
used, and for the aphakic eye (the eye without the lens), a 6 mm. white
disc target will be used. In neither instance should corrective
spectacle lenses be worn during the examination but if they have been
used, this fact must be stated.
Measurements obtained on comparable perimetric devices may be used;
this does not include the use of tangent screen measurements. For
measurements obtained using the Goldmann perimeter, the object size
designation III and the illumination designation 4 should be used for
the phakic eye, and the object size designation IV and illumination
designation 4 for the aphakic eye.
Field measurements must be accompanied by notated field charts, a
description of the type and size of the target and the test distance.
Tangent screen visual fields are not acceptable as a measurement of
peripheral field loss.
Where the loss is predominantly in the lower visual fields, a system
such as the weighted grid scale for perimetric fields described by B.
Esterman (see Grid for Scoring Visual Fields, II. Perimeter, Archives of
Ophthalmology, 79:400, 1968) may be used for determining whether the
visual field loss is comparable to that described in Table 2.
4. Muscle function. Paralysis of the third cranial nerve producing
ptosis, paralysis of accommodation, and dilation and immobility of the
pupil may cause significant visual impairment. When all the muscle of
the eye are paralyzed including the iris and ciliary body (total
ophthalmoplegia), the condition is considered a severe impairment
provided it is bilateral. A finding of severe impairment based primarily
on impaired muscle function must be supported by a report of an actual
measurement of ocular motility.
5. Visual efficiency. Loss of visual efficiency may be caused by
disease or injury resulting in a reduction of central visual acuity or
visual field. 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 and 2, following 2.09.)

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6. Special situations. Aphakia represents a visual handicap in
addition to the loss of central visual acuity. The term monocular
aphakia would apply to an individual who has had the lens removed from
one eye, and who still retains the lens in his other eye, or to an
individual who has only one eye which is aphakic. The term binocular
aphakia would apply to an individual who has had both lenses removed. In
cases of binocular aphakia, the central efficiency of the better eye
will be accepted as 75 percent of its value. In cases of monocular
aphakia, where the better eye is aphakic, the central visual efficiency
will be accepted as 50 percent of the value. (If an individual has
binocular aphakia, and the central visual acuity in the poorer eye can
be corrected only to 20/200, or less, the central visual efficiency of
the better eye will be accepted as 50 percent of its value.)
Ocular symptoms of systemic disease may or may not produce a
disabling visual impairement. These manifestations should be evaluated
as part of the underlying disease entity by reference to the particular
body system involved.
7. Statutory blindness. The term ``statutory blindness'' refers to
the degree of visual impairment which defines the term ``blindness'' in
the Social Security Act. Both 2.02 and 2.03 A and B denote statutory
blindness.
B. Otolaryngology
1. Hearing impairment. Hearing ability should be evaluated in terms
of the person's ability to hear and distinguish speech.
Loss of hearing can be quantitatively determined by an audiometer
which meets the standards of the American National Standards Institute
(ANSI) for air and bone conducted stimuli (i.e., ANSI S 3.6-1969 and
ANSI S 3.13-1972, or subsequent comparable revisions) and performing all
hearing measurements in an environment which meets the ANSI standard for
maximal permissible background sound (ANSI S 3.1-1977).
Speech discrimination should be determined using a standardized
measure of speech discrimination ability in quiet at a test presentation
level sufficient to ascertain maximum discrimination ability. The speech
discrimination measure (test) used, and the level at which testing was
done, must be reported.
Hearing tests should be preceded by an otolaryngologic examination
and should be performed by or under the supervision of an
otolaryngologist or audiologist qualified to perform such tests.
In order to establish an independent medical judgment as to the
level of impairment in a claimant alleging deafness, the following
examinations should be reported: Otolaryngologic examination, pure tone
air and bone audiometry, speech reception threshold (SRT), and speech
discrimination testing. A copy of reports of medical examination and
audiologic evaluations must be submitted.
Cases of alleged ``deaf mutism'' should be documented by a hearing
evaluation. Records obtained from a speech and hearing rehabilitation
center or a special school for the deaf may be acceptable, but if these
reports are not available, or are found to be inadequate, a current
hearing evaluation should be submitted as outlined in the preceding
paragraph.
2. Vertigo associated with disturbances of labyrinthine-vestibular
function, including Meniere's disease. These disturbances of balance are
characterized by an hallucination of motion or loss of position sense
and a sensation of dizziness which may be constant or may occur in
paroxysmal attacks. Nausea, vomiting, ataxia, and incapacitation are
frequently observed, particularly during the acute attack. It is
important to differentiate the report of rotary vertigo from that of
``dizziness'' which is described as lightheadedness, unsteadiness,
confusion, or syncope.
Meniere's disease is characterized by paroxysmal attacks of vertigo,
tinnitus, and fluctuating hearing loss. Remissions are unpredictable and
irregular, but may be longlasting; hence, the severity of impairment is
best determined after prolonged observation and serial reexaminations.
The diagnosis of a vestibular disorder requires a comprehensive
neuro-otolaryngologic examination with a detailed description of the
vertiginous episodes, including notation of frequency, severity, and
duration of the attacks. Pure tone and speech audiometry with the
appropriate special examinations, such as Bekesy audiometry, are
necessary. Vestibular functions is assessed by positional and caloric
testing, preferably by electronystagmography. When polytograms, contrast
radiography, or other special tests have been performed, copies of the
reports of these tests should be obtained in addition to reports of
skull and temporal bone X-rays.
3. Organic loss of speech. Glossectomy or laryngectomy or
cicatricial laryngeal stenosis due to injury or infection results in
loss of voice production by normal means. In evaluating organic loss of
speech (see 2.09), ability to produce speech by any means includes the
use of mechanical or electronic devices. Impairment of speech due to
neurologic disorders should be evaluated under 11.00-11.19.
2.01 Category of Impairments, Special Senses and Speech
2.02 Impairment of central visual acuity. Remaining vision in the
better eye after best correction is 20/200 or less.
2.03 Contraction of peripheral visual fields in the better eye.
A. To 10 deg. or less from the point of fixation; or

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B. So the widest diameter subtends an angle no greater than 20 deg.;
or
C. To 20 percent or less visual field efficiency.
2.04 Loss of visual efficiency. Visual efficiency of better eye
after best correction 20 percent or less. (The percent of remaining
visual efficiency=the product of the percent of remaining central visual
efficiency and the percent of remaining visual field efficiency.)
2.05 Complete homonymous hemianopsia (with or without macular
sparing). Evaluate under 2.04.
2.06 Total bilateral ophthalmoplegia.
2.07 Disturbance of labyrinthine-vestibular function (including
Meniere's disease), characterized by a history of frequent attacks of
balance disturbance, tinnitus, and progressive loss of hearing. With
both A and B:
A. Disturbed function of vestibular labyrinth demonstrated by
caloric or other vestibular tests; and
B. Hearing loss established by audiometry.
2.08 Hearing impairments (hearing not restorable by a hearing aid)
manifested by:
A. Average hearing threshold sensitivity for air conduction of 90
decibels or greater and for bone conduction to corresponding maximal
levels, in the better ear, determined by the simple average of hearing
threshold levels at 500, 1000 and 2000 hz. (see 2.00B1); or
B. Speech discrimination scores of 40 percent or less in the better
ear;
2.09 Organic loss of speech due to any cause with inability to
produce by any means speech which can be heard, understood, and
sustained.

Table No. 1--Percentage of Central Visual Efficiency Corresponding to
Central Visual Acuity Notations for Distance in the Phakic and Aphakic
Eye (Better Eye)
------------------------------------------------------------------------
Snellen Percent central visual efficiency
------------------------------------------------------------------------
Aphakic Aphakic
English Metric Phakic \1\ monocular \2\ binocular \3\
------------------------------------------------------------------------
20/16...... 6/5 100 50 75
20/20...... 6/6 100 50 75
20/25...... 6/7.5 95 47 71
20/32...... 6/10 90 45 67
20/40...... 6/12 85 42 64
20/50...... 6/15 75 37 56
20/64...... 6/20 65 32 49
20/80...... 6/24 60 30 45
20/100..... 6/30 50 25 37
20/125..... 6/38 40 20 30
20/160..... 6/48 30 ............... 22
20/200..... 6/60 20 ............... ...............
------------------------------------------------------------------------
Column and Use.
\1\ Phakic.--1. A lens is present in both eyes. 2. A lens is present in
the better eye and absent in the poorer eye. 3. A lens is present in
one eye and the other eye is enucleated.
\2\ Monocular.--1. A lens is absent in the better eye and present in the
poorer eye. 2. The lenses are absent in both eyes; however, the
central visual acuity in the poorer eye after best correction in 20/
200 or less. 3. A lens is absent from one eye and the other eye is
enucleated.
\3\ Binocular.--1. The lenses are absent from both eyes and the central
visual acuity in the poorer eye after best correction is greater than
20/200.

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[GRAPHIC] [TIFF OMITTED] TR01FE93.040

Table No. 2--Chart of Visual Field Showing Extent of Normal Field and
Method of Computing Percent of Visual Field Efficiency__________________
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 eight
principal meridians of this field total 500 deg..
2. The percent of visual field efficiency is obtained by adding the
number of degrees of the eight principal meridians of the contracted
field and dividing by 500. Diagram of left eye illustrates visual field
contracted to 30 deg. in the temporal and down and out meridians and to
20 deg. in the remaining six meridians. The percent of visual field
efficiency of this field is: 6 x 20+2 x 30 =180500=0.36 or 36
percent remaining visual field efficiency, or 64 percent loss.

3.00 Respiratory System

A. Introduction. The listings in this section describe impairments
resulting from respiratory disorders based on symptoms, physical signs,
laboratory test abnormalities, and response to a regimen of treatment
prescribed by a treating source. Respiratory disorders along with any
associated impairment(s) must be established by medical evidence.
Evidence must be provided in sufficient detail to permit an independent
reviewer to evaluate the severity of the impairment.
Many individuals, especially those who have listing-level
impairments, will have received the benefit of medically prescribed
treatment. Whenever there is evidence of such treatment, the
longitudinal clinical record must include a description of the treatment
prescribed by the treating source and response in addition to
information about the nature and severity of the impairment. It is
important to document any prescribed treatment and response, because
this medical management may have improved the individual's functional
status. The longitudinal record should provide information regarding
functional recovery, if any.
Some individuals will not have received ongoing treatment or have an
ongoing relationship with the medical community, despite the existence
of a severe impairment(s). An individual who does not receive treatment
may or may not be able to show the existence of an impairment that meets
the criteria of these listings. Even if an individual does not show that
his or her impairment meets the criteria of these listings, the
individual may have an impairment(s) equivalent in severity to one of
the listed impairments or be disabled because of a limited residual
functional capacity. Unless the claim can be decided favorably on the
basis of the current evidence, a longitudinal record is still important
because it will provide information about such things as the ongoing
medical severity of the impairment, the level of the individual's

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functioning, and the frequency, severity, and duration of symptoms.
Also, the asthma listing specifically includes a requirement for
continuing signs and symptoms despite a regimen of prescribed treatment.
Impairments caused by chronic disorders of the respiratory system
generally produce irreversible loss of pulmonary function due to
ventilatory impairments, gas exchange abnormalities, or a combination of
both. The most common symptoms attributable to these disorders are
dyspnea on exertion, cough, wheezing, sputum production, hemoptysis, and
chest pain. Because these symptoms are common to many other diseases, a
thorough medical history, physical examination, and chest x-ray or other
appropriate imaging technique are required to establish chronic
pulmonary disease. Pulmonary function testing is required to assess the
severity of the respiratory impairment once a disease process is
established by appropriate clinical and laboratory findings.
Alterations of pulmonary function can be due to obstructive airway
disease (e.g., emphysema, chronic bronchitis, asthma), restrictive
pulmonary disorders with primary loss of lung volume (e.g., pulmonary
resection, thoracoplasty, chest cage deformity as in kyphoscoliosis or
obesity), or infiltrative interstitial disorders (e.g., diffuse
pulmonary fibrosis). Gas exchange abnormalities without significant
airway obstruction can be produced by interstitial disorders. Disorders
involving the pulmonary circulation (e.g., primary pulmonary
hypertension, recurrent thromboembolic disease, primary or secondary
pulmonary vasculitis) can produce pulmonary vascular hypertension and,
eventually, pulmonary heart disease (cor pulmonale) and right heart
failure. Persistent hypoxemia produced by any chronic pulmonary disorder
also can result in chronic pulmonary hypertension and right heart
failure. Chronic infection, caused most frequently by mycobacterial or
mycotic organisms, can produce extensive and progressive lung
destruction resulting in marked loss of pulmonary function. Some
disorders, such as bronchiectasis, cystic fibrosis, and asthma, can be
associated with intermittent exacerbations of such frequency and
intensity that they produce a disabling impairment, even when pulmonary
function during periods of relative clinical stability is relatively
well-maintained.
Respiratory impairments usually can be evaluated under these
listings on the basis of a complete medical history, physical
examination, a chest x-ray or other appropriate imaging techniques, and
spirometric pulmonary function tests. In some situations, most typically
with a diagnosis of diffuse interstitial fibrosis or clinical findings
suggesting cor pulmonale, such as cyanosis or secondary polycythemia, an
impairment may be underestimated on the basis of spirometry alone. More
sophisticated pulmonary function testing may then be necessary to
determine if gas exchange abnormalities contribute to the severity of a
respiratory impairment. Additional testing might include measurement of
diffusing capacity of the lungs for carbon monoxide or resting arterial
blood gases. Measurement of arterial blood gases during exercise is
required infrequently. In disorders of the pulmonary circulation, right
heart catheterization with angiography and/or direct measurement of
pulmonary artery pressure may have been done to establish a diagnosis
and evaluate severity. When performed, the results of the procedure
should be obtained. Cardiac catheterization will not be purchased.
These listings are examples of common respiratory disorders that are
severe enough to prevent a person from engaging in any gainful activity.
When an individual has a medically determinable impairment that is not
listed, an impairment which does not meet a listing, or a combination of
impairments no one of which meets a listing, we will consider whether
the individual's impairment or combination of impairments is medically
equivalent in severity to a listed impairment. Individuals who have an
impairment(s) with a level of severity which does not meet or equal the
criteria of the listings may or may not have the residual functional
capacity (RFC) which would enable them to engage in substantial gainful
activity. Evaluation of the impairment(s) of these individuals will
proceed through the final steps of the sequential evaluation process.
B. Mycobacterial, mycotic, and other chronic persistent infections
of the lung. These disorders are evaluated on the basis of the resulting
limitations in pulmonary function. Evidence of chronic infections, such
as active mycobacterial diseases or mycoses with positive cultures, drug
resistance, enlarging parenchymal lesions, or cavitation, is not, by
itself, a basis for determining that an individual has a disabling
impairment expected to last 12 months. In those unusual cases of
pulmonary infection that persist for a period approaching 12 consecutive
months, the clinical findings, complications, therapeutic
considerations, and prognosis must be carefully assessed to determine
whether, despite relatively well-maintained pulmonary function, the
individual nevertheless has an impairment that is expected to last for
at least 12 consecutive months and prevent gainful activity.
C. Episodic respiratory disease. When a respiratory impairment is
episodic in nature, as can occur with exacerbations of asthma, cystic
fibrosis, bronchiectasis, or chronic

[[Page 395]]

asthmatic bronchitis, the frequency and intensity of episodes that occur
despite prescribed treatment are often the major criteria for
determining the level of impairment. Documentation for these
exacerbations should include available hospital, emergency facility and/
or physician records indicating the dates of treatment; clinical and
laboratory findings on presentation, such as the results of spirometry
and arterial blood gas studies (ABGS); the treatment administered; the
time period required for treatment; and the clinical response. Attacks
of asthma, episodes of bronchitis or pneumonia or hemoptysis (more than
blood-streaked sputum), or respiratory failure as referred to in
paragraph B of 3.03, 3.04, and 3.07, are defined as prolonged
symptomatic episodes lasting one or more days and requiring intensive
treatment, such as intravenous bronchodilator or antibiotic
administration or prolonged inhalational bronchodilator therapy in a
hospital, emergency room or equivalent setting. Hospital admissions are
defined as inpatient hospitalizations for longer than 24 hours. The
medical evidence must also include information documenting adherence to
a prescribed regimen of treatment as well as a description of physical
signs. For asthma, the medical evidence should include spirometric
results obtained between attacks that document the presence of baseline
airflow obstruction.
D. Cystic fibrosis is a disorder that affects either the respiratory
or digestive body systems or both and is responsible for a wide and
variable spectrum of clinical manifestations and complications.
Confirmation of the diagnosis is based upon an elevated sweat sodium
concentration or chloride concentration accompanied by one or more of
the following: the presence of chronic obstructive pulmonary disease,
insufficiency of exocrine pancreatic function, meconium ileus, or a
positive family history. The quantitative pilocarpine iontophoresis
procedure for collection of sweat content must be utilized. Two methods
are acceptable: the ``Procedure for the Quantitative Iontophoretic Sweat
Test for Cystic Fibrosis'' published by the Cystic Fibrosis Foundation
and contained in, ``A Test for Concentration of Electrolytes in Sweat in
Cystic Fibrosis of the Pancreas Utilizing Pilocarpine Iontophoresis,''
Gibson, I.E., and Cooke, R.E., Pediatrics, Vol. 23: 545, 1959; or the
``Wescor Macroduct System.'' To establish the diagnosis of cystic
fibrosis, the sweat sodium or chloride content must be analyzed
quantitatively using an acceptable laboratory technique. Another
diagnostic test is the ``CF gene mutation analysis'' for homozygosity of
the cystic fibrosis gene. The pulmonary manifestations of this disorder
should be evaluated under 3.04. The nonpulmonary aspects of cystic
fibrosis should be evaluated under the digestive body system (5.00).
Because cystic fibrosis may involve the respiratory and digestive body
systems, the combined effects of the involvement of these body systems
must be considered in case adjudication.
E. Documentation of pulmonary function testing. The results of
spirometry that are used for adjudication under paragraphs A and B of
3.02 and paragraph A of 3.04 should be expressed in liters (L), body
temperature and pressure saturated with water vapor (BTPS). The reported
one-second forced expiratory volume (FEV1) and forced vital
capacity (FVC) should represent the largest of at least three
satisfactory forced expiratory maneuvers. Two of the satisfactory
spirograms should be reproducible for both pre-bronchodilator tests and,
if indicated, post-bronchodilator tests. A value is considered
reproducible if it does not differ from the largest value by more than 5
percent or 0.1 L, whichever is greater. The highest values of the
FEV1 and FVC, whether from the same or different tracings, should
be used to assess the severity of the respiratory impairment. Peak flow
should be achieved early in expiration, and the spirogram should have a
smooth contour with gradually decreasing flow throughout expiration. The
zero time for measurement of the FEV1 and FVC, if not distinct,
should be derived by linear back-extrapolation of peak flow to zero
volume. A spirogram is satisfactory for measurement of the FEV1 if
the expiratory volume at the back-extrapolated zero time is less than 5
percent of the FVC or 0.1 L, whichever is greater. The spirogram is
satisfactory for measurement of the FVC if maximal expiratory effort
continues for at least 6 seconds, or if there is a plateau in the
volume-time curve with no detectable change in expired volume (VE)
during the last 2 seconds of maximal expiratory effort.
Spirometry should be repeated after administration of an aerosolized
bronchodilator under supervision of the testing personnel if the pre-
bronchodilator FEV1 value is less than 70 percent of the predicted
normal value. Pulmonary function studies should not be performed unless
the clinical status is stable (e.g., the individual is not having an
asthmatic attack or suffering from an acute respiratory infection or
other chronic illness). Wheezing is common in asthma, chronic
bronchitis, or chronic obstructive pulmonary disease and does not
preclude testing. The effect of the administered bronchodilator in
relieving bronchospasm and improving ventilatory function is assessed by
spirometry. If a bronchodilator is not administered, the reason should
be clearly stated in the report. Pulmonary function studies performed to
assess airflow obstruction without testing after bronchodilators cannot
be used to assess levels of impairment in the range that prevents any
gainful work activity, unless the use of bronchodilators is
contraindicated. Post-

[[Page 396]]

bronchodilator testing should be performed 10 minutes after
bronchodilator administration. The dose and name of the bronchodilator
administered should be specified. The values in paragraphs A and B of
3.02 must only be used as criteria for the level of ventilatory
impairment that exists during the individual's most stable state of
health (i.e., any period in time except during or shortly after an
exacerbation).
The appropriately labeled spirometric tracing, showing the
claimant's name, date of testing, distance per second on the abscissa
and distance per liter (L) on the ordinate, must be incorporated into
the file. The manufacturer and model number of the device used to
measure and record the spirogram should be stated. The testing device
must accurately measure both time and volume, the latter to within 1
percent of a 3 L calibrating volume. If the spirogram was generated by
any means other than direct pen linkage to a mechanical displacement-
type spirometer, the spirometric tracing must show a recorded
calibration of volume units using a mechanical volume input such as a 3
L syringe.
If the spirometer directly measures flow, and volume is derived by
electronic integration, the linearity of the device must be documented
by recording volume calibrations at three different flow rates of
approximately 30 L/min (3 L/6 sec), 60 L/min (3 L/3 sec), and 180 L/min
(3 L/sec). The volume calibrations should agree to within 1 percent of a
3 L calibrating volume. The proximity of the flow sensor to the
individual should be noted, and it should be stated whether or not a
BTPS correction factor was used for the calibration recordings and for
the individual's actual spirograms.
The spirogram must be recorded at a speed of at least 20 mm/sec, and
the recording device must provide a volume excursion of at least 10 mm/
L. If reproductions of the original spirometric tracings are submitted,
they must be legible and have a time scale of at least 20 mm/sec and a
volume scale of at least 10 mm/L to permit independent measurements.
Calculation of FEV1 from a flow-volume tracing is not acceptable,
i.e., the spirogram and calibrations must be presented in a volume-time
format at a speed of at least 20 mm/sec and a volume excursion of at
least 10 mm/L to permit independent evaluation.
A statement should be made in the pulmonary function test report of
the individual's ability to understand directions as well as his or her
effort and cooperation in performing the pulmonary function tests.
The pulmonary function tables in 3.02 and 3.04 are based on
measurement of standing height without shoes. If an individual has
marked spinal deformities (e.g., kyphoscoliosis), the measured span
between the fingertips with the upper extremities abducted 90 degrees
should be substituted for height when this measurement is greater than
the standing height without shoes.
F. Documentation of chronic impairment of gas exchange.
1. Diffusing capacity of the lungs for carbon monoxide (DLCO). A
diffusing capacity of the lungs for carbon monoxide study should be
purchased in cases in which there is documentation of chronic pulmonary
disease, but the existing evidence, including properly performed
spirometry, is not adequate to establish the level of functional
impairment. Before purchasing DLCO measurements, the medical history,
physical examination, reports of chest x-ray or other appropriate
imaging techniques, and spirometric test results must be obtained and
reviewed because favorable decisions can often be made based on
available evidence without the need for DLCO studies. Purchase of a DLCO
study may be appropriate when there is a question of whether an
impairment meets or is equivalent in severity to a listing, and the
claim cannot otherwise be favorably decided.
The DLCO should be measured by the single breath technique with the
individual relaxed and seated. At sea level, the inspired gas mixture
should contain approximately 0.3 percent carbon monoxide (CO), 10
percent helium (He), 21 percent oxygen (O2), and the balance
nitrogen. At altitudes above sea level, the inspired O2
concentration may be raised to provide an inspired O2 tension of
approximately 150 mm Hg. Alternatively, the sea level mixture may be
employed at altitude and the measured DLCO corrected for ambient
barometric pressure. Helium may be replaced by another inert gas at an
appropriate concentration. The inspired volume (VI) during the DLCO
maneuver should be at least 90 percent of the previously determined
vital capacity (VC). The inspiratory time for the VI should be less than
2 seconds, and the breath-hold time should be between 9 and 11 seconds.
The washout volume should be between 0.75 and 1.00 L, unless the VC is
less than 2 L. In this case, the washout volume may be reduced to 0.50
L; any such change should be noted in the report. The alveolar sample
volume should be between 0.5 and 1.0 L and be collected in less than 3
seconds. At least 4 minutes should be allowed for gas washout between
repeat studies.
A DLCO should be reported in units of ml CO, standard temperature,
pressure, dry (STPD)/min/mm Hg uncorrected for hemoglobin concentration
and be based on a single-breath alveolar volume determination. Abnormal
hemoglobin or hematocrit values, and/or carboxyhemoglobin levels should
be reported along with diffusing capacity.
The DLCO value used for adjudication should represent the mean of at
least two acceptable measurements, as defined above. In addition, two
acceptable tests should be within 10 percent of each other or 3 ml

[[Page 397]]

CO(STPD)/min/mm Hg, whichever is larger. The percent difference should
be calculated as 100 x (test 1-test 2)/average DLCO.
The ability of the individual to follow directions and perform the
test properly should be described in the written report. The report
should include tracings of the VI, breath-hold maneuver, and VE
appropriately labeled with the name of the individual and the date of
the test. The time axis should be at least 20 mm/sec and the volume axis
at least 10 mm/L. The percentage concentrations of inspired O2, and
inspired and expired CO and He for each of the maneuvers should be
provided, and the algorithm used to calculate test results noted.
Sufficient data must be provided to permit independent calculation of
results (and, if necessary, calculation of corrections for anemia and/or
carboxyhemoglobin).
2. Arterial blood gas studies (ABGS). An ABGS performed at rest
(while breathing room air, awake and sitting or standing) or during
exercise should be analyzed in a laboratory certified by a State or
Federal agency. If the laboratory is not certified, it must submit
evidence of participation in a national proficiency testing program as
well as acceptable quality control at the time of testing. The report
should include the altitude of the facility and the barometric pressure
on the date of analysis.
Purchase of resting ABGS may be appropriate when there is a question
of whether an impairment meets or is equivalent in severity to a
listing, and the claim cannot otherwise be favorably decided. If the
results of a DLCO study are greater than 40 percent of predicted normal
but less than 60 percent of predicted normal, purchase of resting ABGS
should be considered. Before purchasing resting ABGS, a program
physician, preferably one experienced in the care of patients with
pulmonary disease, must review all clinical and laboratory data short of
this procedure, including spirometry, to determine whether obtaining the
test would present a significant risk to the individual.
3. Exercise testing. Exercise testing with measurement of arterial
blood gases during exercise may be appropriate in cases in which there
is documentation of chronic pulmonary disease, but full development,
short of exercise testing, is not adequate to establish if the
impairment meets or is equivalent in severity to a listing, and the
claim cannot otherwise be favorably decided. In this context, ``full
development'' means that results from spirometry and measurement of DLCO
and resting ABGS have been obtained from treating sources or through
purchase. Exercise arterial blood gas measurements will be required
infrequently and should be purchased only after careful review of the
medical history, physical examination, chest x-ray or other appropriate
imaging techniques, spirometry, DLCO, electrocardiogram (ECG),
hematocrit or hemoglobin, and resting blood gas results by a program
physician, preferably one experienced in the care of patients with
pulmonary disease, to determine whether obtaining the test would
presents a significant risk to the individual. Oximetry and capillary
blood gas analysis are not acceptable substitutes for the measurement of
arterial blood gases. Arterial blood gas samples obtained after the
completion of exercise are not acceptable for establishing an
individual's functional capacity.
Generally, individuals with a DLCO greater than 60 percent of
predicted normal would not be considered for exercise testing with
measurement of blood gas studies. The exercise test facility must be
provided with the claimant's clinical records, reports of chest x-ray or
other appropriate imaging techniques, and any spirometry, DLCO, and
resting blood gas results obtained as evidence of record. The testing
facility must determine whether exercise testing present a significant
risk to the individual; if it does, the reason for not performing the
test must be reported in writing.
4. Methodology. Individuals considered for exercise testing first
should have resting arterial blood partial pressure of oxygen
(PO2), resting arterial blood partial pressure of carbon dioxide
(PCO2) and negative log of hydrogen ion concentration (pH)
determinations by the testing facility. The sample should be obtained in
either the sitting or standing position. The individual should then
perform exercise under steady state conditions, preferably on a
treadmill, breathing room air, for a period of 4 to 6 minutes at a speed
and grade providing an oxygen consumption of approximately 17.5 ml/kg/
min (5 METs). If a bicycle ergometer is used, an exercise equivalent of
5 METs (e.g., 450 kpm/min, or 75 watts, for a 176 pound (80 kilogram)
person) should be used. If the individual is able to complete this level
of exercise without achieving listing-level hypoxemia, then he or she
should be exercised at higher workloads to determine exercise capacity.
A warm-up period of treadmill walking or cycling may be performed to
acquaint the individual with the exercise procedure. If during the warm-
up period the individual cannot achieve an exercise level of 5 METs, a
lower workload may be selected in keeping with the estimate of exercise
capacity. The individual should be monitored by ECG throughout the
exercise and in the immediate post-exercise period. Blood pressure and
an ECG should be recorded during each minute of exercise. During the
final 2 minutes of a specific level of steady state exercise, an
arterial blood sample should be drawn and analyzed for oxygen pressure
(or tension) (PO2), carbon dioxide pressure (or tension)
(PCO2), and pH. At the discretion of the testing facility, the

[[Page 398]]

sample may be obtained either from an indwelling arterial catheter or by
direct arterial puncture. If possible, in order to evaluate exercise
capacity more accurately, a test site should be selected that has the
capability to measure minute ventilation, O2 consumption, and
carbon dioxide (CO2) production. If the claimant fails to complete
4 to 6 minutes of steady state exercise, the testing laboratory should
comment on the reason and report the actual duration and levels of
exercise performed. This comment is necessary to determine if the
individual's test performance was limited by lack of effort or other
impairment (e.g., cardiac, peripheral vascular, musculoskeletal,
neurological).
The exercise test report should contain representative ECG strips
taken before, during and after exercise; resting and exercise arterial
blood gas values; treadmill speed and grade settings, or, if a bicycle
ergometer was used, exercise levels expressed in watts or kpm/min; and
the duration of exercise. Body weight also should be recorded. If
measured, O2 consumption (STPD), minute ventilation (BTPS), and
CO2 production (STPD) also should be reported. The altitude of the
test site, its normal range of blood gas values, and the barometric
pressure on the test date must be noted.
G. Chronic cor pulmonale and pulmonary vascular disease.
The establishment of an impairment attributable to irreversible cor
pulmonale secondary to chronic pulmonary hypertension requires
documentation by signs and laboratory findings of right ventricular
overload or failure (e.g., an early diastolic right-sided gallop on
auscultation, neck vein distension, hepatomegaly, peripheral edema,
right ventricular outflow tract enlargement on x-ray or other
appropriate imaging techniques, right ventricular hypertrophy on ECG,
and increased pulmonary artery pressure measured by right heart
catheterization available from treating sources). Cardiac
catheterization will not be purchased. Because hypoxemia may accompany
heart failure and is also a cause of pulmonary hypertension, and may be
associated with hypoventilation and respiratory acidosis, arterial blood
gases may demonstrate hypoxemia (decreased PO2), CO2 retention
(increased PCO2), and acidosis (decreased pH). Polycythemia with an
elevated red blood cell count and hematocrit may be found in the
presence of chronic hypoxemia.
P-pulmonale on the ECG does not establish chronic pulmonary
hypertension or chronic cor pulmonale. Evidence of florid right heart
failure need not be present at the time of adjudication for a listing
(e.g., 3.09) to be satisfied, but the medical evidence of record should
establish that cor pulmonale is chronic and irreversible.
H. Sleep-related breathing disorders.
Sleep-related breathing disorders (sleep apneas) are caused by
periodic cessation of respiration associated with hypoxemia and frequent
arousals from sleep. Although many individuals with one of these
disorders will respond to prescribed treatment, in some, the disturbed
sleep pattern and associated chronic nocturnal hypoxemia cause daytime
sleepiness with chronic pulmonary hypertension and/or disturbances in
cognitive function. Because daytime sleepiness can affect memory,
orientation, and personality, a longitudinal treatment record may be
needed to evaluate mental functioning. Not all individuals with sleep
apnea develop a functional impairment that affects work activity. When
any gainful work is precluded, the physiologic basis for the impairment
may be chronic cor pulmonale. Chronic hypoxemia due to episodic apnea
may cause pulmonary hypertension (see 3.00G and 3.09). Daytime
somnolence may be associated with disturbance in cognitive vigilance.
Impairment of cognitive function may be evaluated under organic mental
disorders (12.02). If the disorder is associated with gross obesity, it
should be evaluated under the applicable obesity listing.
3.01 Category of Impairments, Respiratory System.
3.02 Chronic pulmonary insufficiency.
A. Chronic obstructive pulmonary disease, due to any cause, with the
FEV1 equal to or less than the values specified in table I
corresponding to the person's height without shoes. (In cases of marked
spinal deformity, see 3.00E.);

Table I
------------------------------------------------------------------------
FEV1
equal to
Height without shoes (centimeters) Height without shoes or less
(inches) than (L,
BTPS)
------------------------------------------------------------------------
154 or less......................... 60 or less............. 1.05
155-160............................. 61-63.................. 1.15
161-165............................. 64-65.................. 1.25
166-170............................. 66-67.................. 1.35
171-175............................. 68-69.................. 1.45
176-180............................. 70-71.................. 1.55
181 or more......................... 72 or more............. 1.65
------------------------------------------------------------------------

B. Chronic restrictive ventilatory disease, due to any cause, with
the FVC equal to or less than the values specified in Table II
corresponding to the person's height without shoes. (In cases of marked
spinal deformity, see 3.00E.);

[[Page 399]]

Table II
------------------------------------------------------------------------
FVC equal
Height without shoes to or
Height without shoes (centimeters) (inches) less than
(L, BTPS)
------------------------------------------------------------------------
154 or less......................... 60 or less............. 1.25
155-160............................. 61-63.................. 1.35
161-165............................. 64-65.................. 1.45
166-170............................. 66-67.................. 1.55
171-175............................. 68-69.................. 1.65
176-180............................. 70-71.................. 1.75
181 or more......................... 72 or more............. 1.85
------------------------------------------------------------------------

C. Chronic impairment of gas exchange due to clinically documented
pulmonary disease. With:
1. Single breath DLCO (see 3.00F1) less than 10.5 ml/min/mm Hg or
less than 40 percent of the predicted normal value. (Predicted values
must either be based on data obtained at the test site or published
values from a laboratory using the same technique as the test site. The
source of the predicted values should be reported. If they are not
published, they should be submitted in the form of a table or nomogram);
or
2. Arterial blood gas values of PO2 and simultaneously
determined PCO2 measured while at rest (breathing room air, awake
and sitting or standing) in a clinically stable condition on at least
two occasions, three or more weeks apart within a 6-month period, equal
to or less than the values specified in the applicable table III-A or
III-B or III-C:

Table III.--A
[Applicable at test sites less than 3,000 feet above sea level]
------------------------------------------------------------------------
Arterial PO2
equal to or
Arterial PCO2 (mm. Hg) and less than (mm.
Hg)
------------------------------------------------------------------------
30 or below............................................. 65
31...................................................... 64
32...................................................... 63
33...................................................... 62
34...................................................... 61
35...................................................... 60
36...................................................... 59
37...................................................... 58
38...................................................... 57
39...................................................... 56
40 or above............................................. 55
------------------------------------------------------------------------

Table III.--B
[Applicable at test sites 3,000 through 6,000 feet above sea level]
------------------------------------------------------------------------
Arterial PO2
equal to or
Arterial PCO2 (mm. Hg) and less than (mm.
Hg)
------------------------------------------------------------------------
30 or below............................................. 60
31...................................................... 59
32...................................................... 58
33...................................................... 57
34...................................................... 56
35...................................................... 55
36...................................................... 54
37...................................................... 53
38...................................................... 52
39...................................................... 51
40 or above............................................. 50
------------------------------------------------------------------------

Table III.--C
[Applicable at test sites over 6,000 feet above sea level]
------------------------------------------------------------------------
Arterial PO2
or equal to or
Arterial PCO2 (mm. Hg) and less than (mm.
Hg)
------------------------------------------------------------------------
30 or below............................................. 55
31...................................................... 54
32...................................................... 53
33...................................................... 52
34...................................................... 51
35...................................................... 50
36...................................................... 49
37...................................................... 48
38...................................................... 47
39...................................................... 46
40 or above............................................. 45
------------------------------------------------------------------------

3. Arterial blood gas values of PO2 and simultaneously
determined PCO2 during steady state exercise breathing room air
(level of exercise equivalent to or less than 17.5 ml O2
consumption/kg/min or 5 METs) equal to or less than the values specified
in the applicable table III-A or III-B or III-C in 3.02C2.
3.03 Asthma. With:
A. Chronic asthmatic bronchitis. Evaluate under the criteria for
chronic obstructive pulmonary disease in 3.02A;

B. Attacks (as defined in 3.00C), in spite of prescribed treatment
and requiring physician intervention, occurring at least once every 2
months or at least six times a year. Each in-patient hospitalization for
longer than 24 hours for control of asthma counts as two attacks, and an
evaluation period of at least 12 consecutive months must be used to
determine the frequency of attacks.
3.04 Cystic fibrosis. With:
A. An FEV1 equal to or less than the appropriate value
specified in table IV corresponding to the individual's height without
shoes. (In cases of marked spinal deformity, see 3.00E.);

[[Page 400]]

C. Persistent pulmonary infection accompanied by superimposed,
recurrent, symptomatic episodes of increased bacterial infection
occurring at least once every 6 months and requiring intravenous or
nebulization antimicrobial therapy.

Table IV
[Applicable only for evaluation under 3.04A--cystic fibrosis]
------------------------------------------------------------------------
FEV1
equal
to or
Height without shoes (centimeters) Height without less
shoes (inches) than
(L,
BTPS)
------------------------------------------------------------------------
154 or less..................................... 60 or less 1.45
155-159......................................... 61-62 1.55
160-164......................................... 63-64 1.65
165-169......................................... 65-66 1.75
170-174......................................... 67-68 1.85
175-179......................................... 69-70 1.95
180 or more..................................... 71 or more 2.05
------------------------------------------------------------------------

3.05 [Reserved]
3.06 Pneumoconiosis (demonstrated by appropriate imaging
techniques). Evaluate under the appropriate criteria in 3.02.
3.07 Bronchiectasis (demonstrated by appropriate imaging
techniques). With:
A. Impairment of pulmonary function due to extensive disease.
Evaluate under the appropriate criteria in 3.02;

B. Episodes of bronchitis or pneumonia or hemoptysis (more than
blood-streaked sputum) or respiratory failure (documented according to
3.00C), requiring physician intervention, occurring at least once every
2 months or at least six times a year. Each in-patient hospitalization
for longer than 24 hours for treatment counts as two episodes, and an
evaluation of at least 12 consecutive months must be used to determine
the frequency of episodes.
3.08 Mycobacterial, mycotic, and other chronic persistent
infections of the lung (see 3.00B). Evaluate under the appropriate
criteria in 3.02.
3.09 Cor pulmonale secondary to chronic pulmonary vascular
hypertension. Clinical evidence of cor pulmonale (documented according
to 3.00G) with:
A. Mean pulmonary artery pressure greater than 40 mm Hg;

B. Arterial hypoxemia. Evaluate under the criteria in 3.02C2;

C. Evaluate under the applicable criteria in 4.02.
3.10 Sleep-related breathing disorders. Evaluate under 3.09
(chronic cor pulmonale), 9.09 (obesity), or 12.02 (organic mental
disorders).

4.00 Cardiovascular System

A. Introduction. The listings in this section describe impairments
resulting from cardiovascular disease based on symptoms, physical signs,
laboratory test abnormalities, and response to a regimen of therapy
prescribed by a treating source. A longitudinal clinical record covering
a period of not less than 3 months of observations and therapy is
usually necessary for the assessment of severity and expected duration
of cardiovascular impairment, unless the claim can be decided favorably
on the basis of the current evidence. All relevant evidence must be
considered in assessing disability.
Many individuals, especially those who have listing-level
impairments, will have received the benefit of medically prescribed
treatment. Whenever there is evidence of such treatment, the
longitudinal clinical record must include a description of the therapy
prescribed by the treating source and response, in addition to
information about the nature and severity of the impairment. It is
important to document any prescribed therapy and response because this
medical management may have improved the individual's functional status.
The longitudinal record should provide information regarding functional
recovery, if any.
Some individuals will not have received ongoing treatment or have an
ongoing relationship with the medical community despite the existence of
a severe impairment(s). Unless the claim can be decided favorably on the
basis of the current evidence, a longitudinal record is still important
because it will provide information about such things as the ongoing
medical severity of the impairment, the degree of recovery from cardiac
insult, the level of the individual's functioning, and the frequency,
severity, and duration of symptoms. Also, several listings include a
requirement for continuing signs and symptoms despite a regimen of
prescribed treatment. Even though an individual who does not receive
treatment may not be able to show an impairment that meets the criteria
of these listings, the individual may have an impairment(s) equivalent
in severity to one

[[Page 401]]

of the listed impairments or be disabled because of a limited residual
functional capacity.
Indeed, it must be remembered that these listings are only examples
of common cardiovascular disorders that are severe enough to prevent a
person from engaging in gainful activity. Therefore, in any case in
which an individual has a medically determinable impairment that is not
listed, or a combination of impairments no one of which meets a listing,
we will make a medical equivalence determination. Individuals who have
an impairment(s) with a level of severity which does not meet or equal
the criteria of the cardiovascular listings may or may not have the
residual functional capacity (RFC) which would enable them to engage in
substantial gainful activity. Evaluation of the impairment(s) of these
individuals should proceed through the final steps of the sequential
evaluation process (or, as appropriate, the steps in the medical
improvement review standard).
B. Cardiovascular impairment results from one or more of four
consequences of heart disease:
1. Chronic heart failure or ventricular dysfunction.
2. Discomfort or pain due to myocardial ischemia, with or without
necrosis of heart muscle.
3. Syncope, or near syncope, due to inadequate cerebral perfusion
from any cardiac cause such as obstruction of flow or disturbance in
rhythm or conduction resulting in inadequate cardiac output.
4. Central cyanosis due to right-to-left shunt, arterial
desaturation, or pulmonary vascular disease.
Impairment from diseases of arteries and veins may result from
disorders of the vasculature in the central nervous system (11.04A, B),
eyes (2.02-2.04), kidney (6.02), and other organs.
C. Documentation. Each individual's file must include sufficiently
detailed reports on history, physical examinations, laboratory studies,
and any prescribed therapy and response to allow an independent reviewer
to assess the severity and duration of the cardiovascular impairment.

1. Electrocardiography

a. An original or legible copy of the 12-lead electrocardiogram
(ECG) obtained at rest must be submitted, appropriately dated and
labeled, with the standardization inscribed on the tracing. Alteration
in standardization of specific leads (such as to accommodate large QRS
amplitudes) must be identified on those leads.
(1) Detailed descriptions or computer-averaged signals without
original or legible copies of the ECG as described in subsection 4.00Cla
are not acceptable.
(2) The effects of drugs or electrolyte abnormalities must be
considered as possible noncoronary causes of ECG abnormalities of
ventricular repolarization, i.e., those involving the ST segment and T
wave. If available, the predrug (especially digitalis glycoside) ECG
should be submitted.
(3) The term ``ischemic'' is used in 4.04A to describe an abnormal
ST segment deviation. Nonspecific repolarization abnormalities should
not be confused with ``ischemic'' changes.
b. ECGs obtained in conjunction with treadmill, bicycle, or arm
exercise tests should meet the following specifications:
(1) ECGs must include the original calibrated ECG tracings or a
legible copy.
(2) A 12-lead baseline ECG must be recorded in the upright position
before exercise.
(3) A 12-lead ECG should be recorded at the end of each minute of
exercise, including at the time the ST segment abnormalities reach or
exceed the criteria for abnormality described in 4.04A or the individual
experiences chest discomfort or other abnormalities, and also when the
exercise test is terminated.
(4) If ECG documentation of the effects of hyperventilation is
obtained, the exercise test should be deferred for at least 10 minutes
because metabolic changes of hyperventilation may alter the physiologic
and ECG response to exercise.
(5) Post-exercise ECGs should be recorded using a generally accepted
protocol consistent with the prevailing state of medical knowledge and
clinical practice.
(6) All resting, exercise, and recovery ECG strips must have a
standardization inscribed on the tracing. The ECG strips should be
labeled to indicate the times recorded and the relationship to the stage
of the exercise protocol. The speed and grade (treadmill test) or work
rate (bicycle or arm ergometric test) should be recorded. The highest
level of exercise achieved, blood pressure levels during testing, and
the reason(s) for terminating the test (including limiting signs or
symptoms) must be recorded.

2. Purchasing Exercise Tests

a. It is well recognized by medical experts that exercise testing is
the best tool currently available for estimating maximal aerobic
capacity in individuals with cardiovascular impairments. Purchase of an
exercise test may be appropriate when there is a question whether an
impairment meets or is equivalent in severity to one of the listings, or
when there is insufficient evidence in the record to evaluate aerobic
capacity, and the claim cannot otherwise be favorably decided. Before
purchasing an exercise test, a program physician, preferably one with
experience in the care of patients with cardiovascular disease, must
review the pertinent

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history, physical examinations, and laboratory tests to determine
whether obtaining the test would present a significant risk to the
individual (see 4.00C2c). Purchase may be indicated when there is no
significant risk to exercise testing and there is no timely test of
record. An exercise test is generally considered timely for 12 months
after the date performed, provided there has been no change in clinical
status that may alter the severity of the cardiac impairment.
b. Methodology.
(1) When an exercise test is purchased, it should be a ``sign-or
symptom-limited'' test characterized by a progressive multistage
regimen. A purchased exercise test must be performed using a generally
accepted protocol consistent with the prevailing state of medical
knowledge and clinical practice. A description of the protocol that was
followed must be provided, and the test must meet the requirements of
4.00C1b and this section. A pre-exercise posthyperventilation tracing
may be essential for the proper evaluation of an ``abnormal'' test in
certain circumstances, such as in women with evidence of mitral valve
prolapse.
(2) The exercise test should be paced to the capabilities of the
individual and be supervised by a physician. With a treadmill test, the
speed, grade (incline) and duration of exercise must be recorded for
each exercise test stage performed. Other exercise test protocols or
techniques that are used should utilize similar workloads.
(3) Levels of exercise should be described in terms of workload and
duration of each stage, e.g., treadmill speed and grade, or bicycle
ergometer work rate in kpm/min or watts.
(4) Normally, systolic blood pressure and heart rate increase
gradually with exercise. A decrease in systolic blood pressure during
exercise below the usual resting level is often associated with
ischemia-induced left ventricular dysfunction resulting in decreased
cardiac output. Some individuals (because of deconditioning or
apprehension) with increased sympathetic responses may increase their
systolic blood pressure and heart rate above their usual resting level
just before and early into exercise. This occurrence may limit the
ability to assess the significance of an early decrease in systolic
blood pressure and heart rate if exercise is discontinued shortly after
initiation. In addition, isolated systolic hypertension may be a
manifestation of arteriosclerosis.
(5) The exercise laboratory's physical environment, staffing, and
equipment should meet the generally accepted standards for adult
exercise test laboratories.
c. Risk factors in exercise testing. The following are examples of
situations in which exercise testing will not be purchased: unstable
progressive angina pectoris, a history of acute myocardial infarction
within the past 3 months, New York Heart Association (NYHA) class IV
heart failure, cardiac drug toxicity, uncontrolled serious arrhythmia
(including uncontrolled atrial fibrillation, Mobitz II, and third-degree
block), Wolff-Parkinson-White syndrome, uncontrolled severe systemic
arterial hypertension, marked pulmonary hypertension, unrepaired aortic
dissection, left main stenosis of 50 percent or greater, marked aortic
stenosis, chronic or dissecting aortic aneurysm, recent pulmonary
embolism, hypertrophic cardiomyopathy, limiting neurological or
musculoskeletal impairments, or an acute illness. In addition, an
exercise test should not be purchased for individuals for whom the
performance of the test is considered to constitute a significant risk
by a program physician, preferably one experienced in the care of
patients with cardiovascular disease, even in the absence of any of the
above risk factors. In defining risk, the program physician, in
accordance with the regulations and other instructions on consultative
examinations, will generally give great weight to the treating
physicians' opinions and will generally not override them. In the rare
situation in which the program physician does override the treating
source's opinion, a written rationale must be prepared documenting the
reasons for overriding the opinion.
d. In order to permit maximal, attainable restoration of functional
capacity, exercise testing should not be purchased until 3 months after
an acute myocardial infarction, surgical myocardial revascularization,
or other open-heart surgical procedures. Purchase of an exercise test
should also be deferred for 3 months after percutaneous transluminal
coronary angioplasty because restenosis with ischemic symptoms may occur
within a few months of angioplasty (see 4.00D). Also, individuals who
have had a period of bedrest or inactivity (e.g., 2 weeks) that results
in a reversible deconditioned state may do poorly if exercise testing is
performed at that time.
e. Evaluation.
(1) Exercise testing is evaluated on the basis of the work level at
which the test becomes abnormal, as documented by onset of signs or
symptoms and any ECG abnormalities listed in 4.04A. The ability or
inability to complete an exercise test is not, by itself, evidence that
a person is free from ischemic heart disease. The results of an exercise
test must be considered in the context of all of the other evidence in
the individual's case record. If the individual is under the care of a
treating physician for a cardiac impairment, and this physician has not
performed an exercise test and there are no reported significant risks
to testing (see 4.00C2c), a statement should be requested from the
treating physician explaining why it was not done or should not be done
before deciding

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whether an exercise test should be purchased. In those rare situations
in which the treating source's opinion is overridden, follow 4.00C2c. If
there is no treating physician, the program physician will be
responsible for assessing the risk to exercise testing.
(2) Limitations to exercise test interpretation include the presence
of noncoronary or nonischemic factors that may influence the hemodynamic
and ECG response to exercise, such as hypokalemia or other electrolyte
abnormality, hyperventilation, vasoregulatory deconditioning, prolonged
periods of physical inactivity (e.g., 2 weeks of bedrest), significant
anemia, left bundle branch block pattern on the ECG (and other
conduction abnormalities that do not preclude the purchase of exercise
testing), and other heart diseases or abnormalities (particularly
valvular heart disease). Digitalis glycosides may cause ST segment
abnormalities at rest, during, and after exercise. Digitalis or other
drug-related ST segment displacement, present at rest, may become
accentuated with exercise and make ECG interpretation difficult, but
such drugs do not invalidate an otherwise normal exercise test.
Diuretic-induced hypokalemia and left ventricular hypertrophy may also
be associated with repolarization changes and behave similarly. Finally,
treatment with beta blockers slows the heart rate more at near-maximal
exertion than at rest; this limits apparent chronotropic capacity.

3. Other Studies

Information from two-dimensional and Doppler echocardiographic
studies of ventricular size and function as well as radionuclide
(thallium 201) myocardial ``perfusion'' or radionuclide (technetium
99m) ventriculograms (RVG or MUGA) may be useful. These techniques can
provide a reliable estimate of ejection fraction. In selected cases,
these tests may be purchased after a medical history and physical
examination, report of chest x-rays, ECGs, and other appropriate tests
have been evaluated, preferably by a program physician with experience
in the care of patients with cardiovascular disease. Purchase should be
considered when other information available is not adequate to assess
whether the individual may have severe ventricular dysfunction or
myocardial ischemia and there is no significant risk involved (follow
4.00C2a guides), and the claim cannot be favorably decided on any other
basis.
Exercise testing with measurement of maximal oxygen uptake (VO
2) provides an accurate determination of aerobic capacity. An
exercise test without measurement of oxygen uptake provides an estimate
of aerobic capacity. When the results of tests with measurement of
oxygen uptake are available, every reasonable effort should be made to
obtain them.
The recording of properly calibrated ambulatory ECGs for analysis of
ST segment signals with a concomitantly recorded symptom and treatment
log may permit more adequate evaluation of chest discomfort during
activities of daily living, but the significance of these data for
disability evaluation has not been established in the absence of
symptoms (e.g., silent ischemia). This information (including selected
segments of both the ECG recording and summary report of the patient
diary) may be submitted for the record.
4. Cardiac catheterization will not be purchased by the Social
Security Administration.
a. Coronary arteriography. If results of such testing are available,
the report should be obtained and considered as to the quality and type
of data provided and its relevance to the evaluation of the impairment.
A copy of the report of the cardiac catheterization and ancillary
studies should also be obtained. The report should provide information
citing the method of assessing coronary arterial lumen diameter and the
nature and location of obstructive lesions. Drug treatment at baseline
and during the procedure should be reported. Coronary artery spasm
induced by intracoronary catheterization is not to be considered
evidence of ischemic disease. Some individuals with significant coronary
atherosclerotic obstruction have collateral vessels that supply the
myocardium distal to the arterial obstruction so that there is no
evidence of myocardial damage or ischemia, even with exercise. When
available, quantitative computer measurements and analyses should be
considered in the interpretation of severity of stenotic lesions.
b. Left ventriculography (by angiography). The report should
describe the wall motion of the myocardium with regard to any areas of
hypokinesis, akinesis, or dyskinesis, and the overall contraction of the
ventricle as measured by the ejection fraction. Measurement of chamber
volumes and pressures may be useful. When available, quantitative
computer analysis provides precise measurement of segmental left
ventricular wall thickness and motion. There is often a poor correlation
between left ventricular function at rest and functional capacity for
physical activity.
D. Treatment and relationship to functional status.
1. In general, conclusions about the severity of a cardiovascular
impairment cannot be made on the basis of type of treatment rendered or
anticipated. The overall clinical and laboratory evidence, including the
treatment plan(s) or results, should be persuasive that a listing-level
impairment exists. The amount of function restored and the time required
for improvement after treatment

[[Page 404]]

(medical, surgical, or a prescribed program of progressive physical
activity) vary with the nature and extent of the disorder, the type of
treatment, and other factors. Depending upon the timing of this
treatment in relation to the alleged onset date of disability,
impairment evaluation may need to be deferred for a period of up to 3
months from the date of treatment to permit consideration of treatment
effects. Evaluation should not be deferred if the claim can be favorably
decided based upon the available evidence.
2. The usual time after myocardial infarction, valvular and/or
revascularization surgery for adequate assessment of the results of
treatment is considered to be 3 months. If an exercise test is performed
by a treating source within a week or two after angioplasty, and there
is no significant change in clinical status during the 3-month period
after the angioplasty that would invalidate the implications of the
exercise test results, the exercise test results may be used to reflect
functional capacity during the period in question. However, if the test
was done immediately following an acute myocardial infarction or during
a period of protracted inactivity, the results should not be projected
to 3 months even if there is no change in clinical status.
3. An individual who has undergone cardiac transplantation will be
considered under a disability for 1 year following the surgery because,
during the first year, there is a greater likelihood of rejection of the
organ and recurrent infection. After the first year posttransplantation,
continuing disability evaluation will be based upon residual impairment
as shown by symptoms, signs, and laboratory findings. Absence of
symptoms, signs, and laboratory findings indicative of cardiac
dysfunction will be included in the consideration of whether medical
improvement (as defined in Secs. 404.1579(b)(1) and (c)(1),
404.1594(b)(1) and (c)(1), or 416.994(b)(1)(i) and (b)(2)(i), as
appropriate) has occurred.
E. Clinical syndromes.
1. Chronic heart failure (ventricular dysfunction) is considered in
these listings as one category whatever its etiology, i.e.,
atherosclerotic, hypertensive, rheumatic, pulmonary, congenital or other
organic heart disease. Chronic heart failure may manifest itself by:
a. Pulmonary or systemic congestion, or both; or
b. Symptoms of limited cardiac output, such as weakness, fatigue, or
intolerance of physical activity.
For the purpose of 4.02A, pulmonary and systemic congestion are not
considered to have been established unless there is or has been evidence
of fluid retention, such as hepatomegaly or ascites, or peripheral or
pulmonary edema of cardiac origin. The findings of fluid retention need
not be present at the time of adjudication because congestion may be
controlled with medication. Chronic heart failure due to limited cardiac
output is not considered to have been established for the purpose of
4.02B unless symptoms occur with ordinary daily activities, i.e.,
activity restriction as manifested by a need to decrease activity or
pace, or to rest intermittently, and are associated with one or more
physical signs or abnormal laboratory studies listed in 4.02B. These
studies include exercise testing with ECG and blood pressure recording
and/or appropriate imaging techniques, such as two-dimensional
echocardiography or radionuclide or contrast ventriculography. The
exercise criteria are outlined in 4.02B1. In addition, other abnormal
symptoms, signs, or laboratory test results that lend credence to the
impression of ventricular dysfunction should be considered.
2. For the purposes of 4.03, hypertensive cardiovascular disease is
evaluated by reference to the specific organ system involved (heart,
brain, kidneys, or eyes). The presence of organic impairment must be
established by appropriate physical signs and laboratory test
abnormalities as specified in 4.02 or 4.04, or for the body system
involved.
3. Ischemic (coronary) heart disease may result in an impairment due
to myocardial ischemia and/or ventricular dysfunction or infarction. For
the purposes of 4.04, the clinical determination that discomfort of
myocardial ischemic origin (angina pectoris) is present must be
supported by objective evidence as described under 4.00Cl, 2, 3, or 4.
a. Discomfort of myocardial ischemic origin (angina pectoris) is
discomfort that is precipitated by effort and/or emotion and promptly
relieved by sublingual nitroglycerin, other rapidly acting nitrates, or
rest. Typically the discomfort is located in the chest (usually
substernal) and described as crushing, squeezing, burning, aching, or
oppressive. Sharp, sticking, or cramping discomfort is considered less
common or atypical. Discomfort occurring with activity or emotion should
be described specifically as to timing and usual inciting factors (type
and intensity), character, location, radiation, duration, and response
to nitrate therapy or rest.
b. So-called anginal equivalent may be localized to the neck,
jaw(s), or hand(s) and has the same precipitating and relieving factors
as typical chest discomfort. Isolated shortness of breath (dyspnea) is
not considered an anginal equivalent for purposes of adjudication.
c. Variant angina of the Prinzmetal type, i.e., rest angina with
transitory ST segment elevation on ECG, may have the same significance
as typical angina, described in 4.00E3a.
d. If there is documented evidence of silent ischemia or restricted
activity to prevent chest discomfort, this information must be

[[Page 405]]

considered along with all available evidence to determine if an
equivalence decision is appropriate.
e. Chest discomfort of myocardial ischemic origin is usually caused
by coronary artery disease. However, ischemic discomfort may be caused
by noncoronary artery conditions, such as critical aortic stenosis,
hypertrophic cardiomyopathy, pulmonary hypertension, or anemia. These
conditions should be distinguished from coronary artery disease, because
the evaluation criteria, management, and prognosis (duration) may differ
from that of coronary artery disease.
f. Chest discomfort of nonischemic origin may result from other
cardiac conditions such as pericarditis and mitral valve prolapse.
Noncardiac conditions may also produce symptoms mimicking that of
myocardial ischemia. These conditions include gastrointestinal tract
disorders, such as esophageal spasm, esophagitis, hiatal hernia, biliary
tract disease, gastritis, peptic ulcer, and pancreatitis, and
musculoskeletal syndromes, such as chest wall muscle spasm, chest wall
syndrome (especially after coronary bypass surgery), costochondritis,
and cervical or dorsal arthritis. Hyperventilation may also mimic
ischemic discomfort. Such disorders should be considered before
concluding that chest discomfort is of myocardial ischemic origin.

4. Peripheral Arterial Disease

The level of impairment is based on the symptomatology, physical
findings, Doppler studies before and after a standard exercise test, or
angiographic findings.
The requirements for evaluating peripheral arterial disease in 4.12B
are based on the ratio of the systolic blood pressure at the ankle to
the systolic blood pressure at the brachial artery, determined in the
supine position at the same time. Techniques for obtaining ankle
systolic blood pressures include Doppler, plethysmographic studies, or
other techniques.
Listing 4.12B1 is met when the resting ankle/brachial systolic blood
pressure ratio is less than 0.50. Listing 4.12B2 provides additional
criteria for evaluating peripheral arterial impairment on the basis of
exercise studies when the resting ankle/brachial systolic blood pressure
ratio is 0.50 or above. The decision to obtain exercise studies should
be based on an evaluation of the existing clinical evidence, but
exercise studies are rarely warranted when the resting ankle-over-
brachial systolic blood pressure ratio is 0.80 or above. The results of
exercise studies should describe the level of exercise, e.g., speed and
grade of the treadmill settings, the duration of exercise, symptoms
during exercise, the reasons for stopping exercise if the expected level
of exercise was not attained, blood pressures at the ankle and other
pertinent sites measured after exercise, and the time required to return
the systolic blood pressure toward or to the pre-exercise level. When an
exercise Doppler study is purchased by the Social Security
Administration, the requested exercise must be on a treadmill at 2 mph
on a 10 or 12 percent grade for 5 minutes. Exercise studies should not
be performed on individuals for whom exercise poses a significant risk.
Application of the criteria in 4.12B may be limited in individuals
who have marked calcific (Monckeberg's) sclerosis of the peripheral
arteries or marked small vessel disease associated with diabetes
mellitus.

4.01 Category of Impairments, Cardiovascular System

4.02 Chronic heart failure while on a regimen of prescribed
treatment (see 4.00A if there is no regimen of prescribed treatment).
With one of the following:
A. Documented cardiac enlargement by appropriate imaging techniques
(e.g., a cardiothoracic ratio of greater than 0.50 on a PA chest x-ray
with good inspiratory effort or left ventricular diastolic diameter of
greater than 5.5 cm on two-dimensional echocardiography), resulting in
inability to carry on any physical activity, and with symptoms of
inadequate cardiac output, pulmonary congestion, systemic congestion, or
anginal syndrome at rest (e.g., recurrent or persistent fatigue,
dyspnea, orthopnea, anginal discomfort);
OR
B. Documented cardiac enlargement by appropriate imaging techniques
(see 4.02A) or ventricular dysfunction manifested by S3, abnormal wall
motion, or left ventricular ejection fraction of 30 percent or less by
appropriate imaging techniques; and
1. Inability to perform on an exercise test at a workload equivalent
to 5 METs or less due to symptoms of chronic heart failure, or, in rare
instances, a need to stop exercise testing at less than this level of
work because of:
a. Three or more consecutive ventricular premature beats or three or
more multiform beats; or
b. Failure to increase systolic blood pressure by 10 mmHg, or
decrease in systolic pressure below the usual resting level (see
4.00C2b); or
c. Signs attributable to inadequate cerebral perfusion, such as
ataxic gait or mental confusion; and
2. Resulting in marked limitation of physical activity, as
demonstrated by fatigue, palpitation, dyspnea, or anginal discomfort on
ordinary physical activity, even though the individual is comfortable at
rest;
OR
C. Cor pulmonale fulfilling the criteria in 4.02A or B.

[[Page 406]]

4.03 Hypertensive cardiovascular disease. Evaluate under 4.02 or
4.04, or under the criteria for the affected body system (2.02 through
2.04, 6.02, or 11.04A or B).
4.04 Ischemic heart disease, with chest discomfort associated with
myocardial ischemia, as described in 4.00E3, while on a regimen of
prescribed treatment (see 4.00A if there is no regimen of prescribed
treatment). With one of the following:
A. Sign- or symptom-limited exercise test demonstrating at least one
of the following manifestations at a workload equivalent to 5 METs or
less:
1. Horizontal or downsloping depression, in the absence of digitalis
glycoside therapy and/or hypokalemia, of the ST segment of at least
-0.10 millivolts (-1.0 mm) in at least 3 consecutive complexes that are
on a level baseline in any lead (other than aVR) and that have a typical
ischemic time course of development and resolution (progression of
horizontal or downsloping ST depression with exercise, and persistence
of depression of at least -0.10 millivolts for at least 1 minute of
recovery); or
2. An upsloping ST junction depression, in the absence of digitalis
glycoside therapy and/or hypokalemia, in any lead (except aVR) of at
least -0.2 millivolts or more for at least 0.08 seconds after the J
junction and persisting for at least 1 minute of recovery; or
3. At least 0.1 millivolt (1 mm) ST elevation above resting baseline
during both exercise and 3 or more minutes of recovery in ECG leads with
low R and T waves in the leads demonstrating the ST segment
displacement; or
4. Failure to increase systolic pressure by 10 mmHg, or decrease in
systolic pressure below usual clinical resting level (see 4.00C2b); or
5. Documented reversible radionuclide ``perfusion''
(thallium^{201) defect at an exercise level equivalent to 5 METs or
less;
OR
B. Impaired myocardial function, documented by evidence (as outlined
under 4.00C3 or 4.00C4b) of hypokinetic, akinetic, or dyskinetic
myocardial free wall or septal wall motion with left ventricular
ejection fraction of 30 percent or less, and an evaluating program
physician, preferably one experienced in the care of patients with
cardiovascular disease, has concluded that performance of exercise
testing would present a significant risk to the individual, and
resulting in marked limitation of physical activity, as demonstrated by
fatigue, palpitation, dyspnea, or anginal discomfort on ordinary
physical activity, even though the individual is comfortable at rest;
OR
C. Coronary artery disease, demonstrated by angiography (obtained
independent of Social Security disability evaluation), and an evaluating
program physician, preferably one experienced in the care of patients
with cardiovascular disease, has concluded that performance of exercise
testing would present a significant risk to the individual, with both 1
and 2:
1. Angiographic evidence revealing:
a. 50 percent or more narrowing of a nonbypassed left main coronary
artery; or
b. 70 percent or more narrowing of another nonbypassed coronary
artery; or
c. 50 percent or more narrowing involving a long (greater than 1 cm)
segment of a nonbypassed coronary artery; or
d. 50 percent or more narrowing of at least 2 nonbypassed coronary
arteries; or
e. Total obstruction of a bypass graft vessel; and
2. Resulting in marked limitation of physical activity, as
demonstrated by fatigue, palpitation, dyspnea, or anginal discomfort on
ordinary physical activity, even though the individual is comfortable at
rest.
4.05 Recurrent arrhythmias, not related to reversible causes such
as electrolyte abnormalities or digitalis glycoside or antiarrhythmic
drug toxicity, resulting in uncontrolled repeated episodes of cardiac
syncope or near syncope and arrhythmia despite prescribed treatment (see
4.00A if there is no prescribed treatment), documented by resting or
ambulatory (Holter) electrocardiography coincident with the occurrence
of syncope or near syncope.
4.06 Symptomatic congenital heart disease (cyanotic or acyanotic),
documented by appropriate imaging techniques (as outlined under 4.00C3)
or cardiac catheterization. With one of the following:
A. Cyanosis at rest, and:
1. Hematocrit of 55 percent or greater, or
2. Arterial O2 saturation of less than 90 percent in room air,
or resting arterial PO2 of 60 Torr or less;
OR
B. Intermittent right-to-left shunting resulting in cyanosis on
exertion (e.g., Eisenmenger's physiology) and with arterial PO2 of
60 Torr or less at a workload equivalent to 5 METs or less;
OR
C. Chronic heart failure with evidence of ventricular dysfunction,
as described in 4.02;
OR
D. Recurrent arrhythmias as described in 4.05;
OR
E. Secondary pulmonary vascular obstructive disease with a mean
pulmonary arterial pressure elevated to at least 70 percent of the mean
systemic arterial pressure.
4.07 Valvular heart disease or other stenotic defects, or valvular
regurgitation, documented by appropriate imaging techniques or cardiac
catheterization. Evaluate under the criteria in 4.02, 4.04, 4.05, or
11.04.

[[Page 407]]

4.08 Cardiomyopathies, documented by appropriate imaging techniques
or cardiac catheterization. Evaluate under the criteria in 4.02, 4.04,
4.05, or 11.04.
4.09 Cardiac transplantation. Consider under a disability for 1
year following surgery; thereafter, reevaluate residual impairment under
4.02 to 4.08.
4.10 Aneurysm of aorta or major branches, due to any cause (e.g.,
atherosclerosis, cystic medial necrosis, Marfan syndrome, trauma),
demonstrated by an appropriate imaging technique. With one of the
following:
A. Acute or chronic dissection not controlled by prescribed medical
or surgical treatment;
OR
B. Chronic heart failure as described under 4.02;
OR
C. Renal failure as described under 6.02;
OR
D. Neurological complications as described under 11.04.
4.11 Chronic venous insufficiency of a lower extremity. With
incompetency or obstruction of the deep venous system and one of the
following:
A. Extensive brawny edema;
OR
B. Superficial varicosities, stasis dermatitis, and recurrent or
persistent ulceration which has not healed following at least 3 months
of prescribed medical or surgical therapy.
4.12 Peripheral arterial disease. With one of the following:
A. Intermittent claudication with failure to visualize (on
arteriogram obtained independent of Social Security disability
evaluation) the common femoral or deep femoral artery in one extremity;
OR
B. Intermittent claudication with marked impairment of peripheral
arterial circulation as determined by Doppler studies showing:
1. Resting ankle/brachial systolic blood pressure ratio of less than
0.50; or
2. Decrease in systolic blood pressure at the ankle on exercise (see
4.00E4) of 50 percent or more of pre-exercise level at the ankle, and
requiring 10 minutes or more to return to pre-exercise level;
OR
C. Amputation at or above the tarsal region due to peripheral
vascular disease.

5.00 Digestive System

A. Disorders of the digestive system which result in a marked
impairment usually do so because of interference with nutrition,
multiple recurrent inflammatory lesions, or complications of disease,
such as fistulae, abscesses, or recurrent obstruction. Such
complications usually respond to treatment. These complications must be
shown to persist on repeated examinations despite therapy for a
reasonable presumption to be made that a marked impairment will last for
a continuous period of at least 12 months.
B. Malnutrition or weight loss from gastrointestinal disorders. When
the primary disorder of the digestive tract has been established (e.g.
enterocolitis, chronic pancreatitis, postgastrointestinal resection, or
esophageal stricture, stenosis, or obstruction), the resultant
interference with nutrition will be considered under the criteria in
5.08. This will apply whether the weight loss is due to primary or
secondary disorders of malabsorption, malassimilation or obstruction.
However, weight loss not due to diseases of the digestive tract, but
associated with psychiatric or primary endocrine or other disorders,
should be evaluated under the appropriate criteria for the underlying
disorder.
C. Surgical diversion of the intestinal tract, including colostomy
or ileostomy, are not listed since they do not represent impairments
which preclude all work activity if the individual is able to maintain
adequate nutrition and function of the stoma. Dumping syndrome which may
follow gastric resection rarely represents a marked impairment which
would continue for 12 months. Peptic ulcer disease with recurrent
ulceration after definitive surgery ordinarily responds to treatment. A
recurrent ulcer after definitive surgery must be demonstrated on
repeated upper gastrointestinal roentgenograms or gastroscopic
examinations despite therapy to be considered a severe impairment which
will last for at least 12 months. Definitive surgical procedures are
those designed to control the ulcer disease process (i.e., vagotomy and
pyloroplasty, subtotal gastrectomy, etc.). Simple closure of a
perforated ulcer does not constitute definitive surgical therapy for
peptic ulcer disease.
5.01 Category of Impairments, Digestive System
5.02 Recurrent upper gastrointestinal hemorrhage from undetermined
cause with anemia manifested by hematocrit of 30 percent or less on
repeated examinations.
5.03 Stricture, stenosis, or obstruction of the esophagus
(demonstrated by X-ray or endoscopy) with weight loss as described under
Sec. 5.08.
5.04 Peptic ulcer disease (demonstrated by X-ray or endoscopy).
With:
A. Recurrent ulceration after definitive surgery persistent despite
therapy; or
B. Inoperable fistula formation; or
C. Recurrent obstruction demonstrated by X-ray or endoscopy. or
D. Weight loss as described under Sec. 5.08.
5.05 Chronic liver disease (e.g., portal, postnecrotic, or biliary
cirrhosis; chronic active hepatitis; Wilson's disease). With:
A. Esophageal varices (demonstrated by X-ray or endoscopy) with a
documented history of massive hemorrhage attributable to these

[[Page 408]]

varices. Consider under a disability for 3 years following the last
massive hemorrhage; thereafter, evaluate the residual impairment; or
B. Performance of a shunt operation for esophageal varices. Consider
under a disability for 3 years following surgery; thereafter, evaluate
the residual impairment; or
C. Serum bilirubin of 2.5 mg. per deciliter (100 ml.) or greater
persisting on repeated examinations for at least 5 months; or
D. Ascites, not attributable to other causes, recurrent or
persisting for at least 5 months, demonstrated by abdominal paracentesis
or associated with persistent hypoalbuminemia of 3.0 gm. per deciliter
(100 ml.) or less; or
E. Hepatic encephalopathy. Evaluate under the criteria in listing
12.02; or
F. Confirmation of chronic liver disease by liver biopsy (obtained
independent of Social Security disability evaluation) and one of the
following:
1. Ascites not attributable to other causes, recurrent or persisting
for at least 3 months, demonstrated by abdominal paracentesis or
associated with persistent hypoalbuminemia of 3.0 gm. per deciliter (100
ml.) or less; or
2. Serum bilirubin of 2.5 mg. per deciliter (100 ml) or greater on
repeated examinations for at least 3 months; or
3. Hepatic cell necrosis or inflammation, persisting for at least 3
months, documented by repeated abnormalities of prothrombin time and
enzymes indicative of hepatic dysfunction.
5.06 Chronic ulcerative or granulomatous colitis (demonstrated by
endoscopy, barium enema, biopsy, or operative findings). With:
A. Recurrent bloody stools documented on repeated examinations and
anemia manifested by hematocrit of 30 percent or less on repeated
examinations; or
B. Persistent or recurrent systemic manifestations, such as
arthritis, iritis, fever, or liver dysfunction, not attributable to
other causes; or
C. Intermittent obstruction due to intractable abscess, fistula
formation, or stenosis; or
D. Recurrence of findings of A, B, or C above after total colectomy;
or
E. Weight loss as described under Sec. 5.08.
5.07 Regional enteritis (demonstrated by operative findings, barium
studies, biopsy, or endoscopy). With:
A. Persistent or recurrent intestinal obstruction evidenced by
abdominal pain, distention, nausea, and vomiting and accompanied by
stenotic areas of small bowel with proximal intestinal dilation; or
B. Persistent or recurrent systemic manifestations such as
arthritis, iritis, fever, or liver dysfunction, not attributable to
other causes; or
C. Intermittent obstruction due to intractable abscess or fistula
formation; or
D. Weight loss as described under Sec. 5.08.
5.08 Weight loss due to any persisting gastrointestinal disorder:
(The following weights are to be demonstrated to have persisted for at
least 3 months despite prescribed therapy and expected to persist at
this level for at least 12 months.) With:
A. Weight equal to or less than the values specified in Table I or
II; or
B. Weight equal to or less than the values specified in Table III or
IV and one of the following abnormal findings on repeated examinations:
1. Serum albumin of 3.0 gm. per deciliter (100 ml.) or less; or
2. Hematocrit of 30 percent or less; or
3. Serum calcium of 8.0 mg. per deciliter (100 ml.) (4.0 mEq./L) or
less; or
4. Uncontrolled diabetes mellitus due to pancreatic dysfunction with
repeated hyperglycemia, hypoglycemia, or ketosis; or
5. Fat in stool of 7 gm. or greater per 24-hour stool specimen; or
6. Nitrogen in stool of 3 gm, or greater per 24-hour specimen; or
7. Persistent or recurrent ascites or edema not attributable to
other causes.
Tables of weight reflecting malnutrition scaled according to height
and sex--To be used only in connection with 5.08.

Table I--Men
------------------------------------------------------------------------
Weight
Height (inches) \1\ (pounds)
------------------------------------------------------------------------
61............................................................ 90
62............................................................ 92
63............................................................ 94
64............................................................ 97
65............................................................ 99
66............................................................ 102
67............................................................ 106
68............................................................ 109
69............................................................ 112
70............................................................ 115
71............................................................ 118
72............................................................ 122
73............................................................ 125
74............................................................ 128
75............................................................ 131
76............................................................ 134
------------------------------------------------------------------------
\1\ Height measured without shoes.

Table II--Women
------------------------------------------------------------------------
Weight
Height (inches) \1\ (pounds)
------------------------------------------------------------------------
58............................................................ 77
59............................................................ 79
60............................................................ 82
61............................................................ 84
62............................................................ 86
63............................................................ 89
64............................................................ 91
65............................................................ 94
66............................................................ 98
67............................................................ 101
68............................................................ 104
69............................................................ 107

[[Page 409]]

70............................................................ 110
71............................................................ 114
72............................................................ 117
73............................................................ 120
------------------------------------------------------------------------
\1\ Height measured without shoes.

Table III--Men
------------------------------------------------------------------------
Weight
Height (inches) \1\ (pounds)
------------------------------------------------------------------------
61............................................................ 95
62............................................................ 98
63............................................................ 100
64............................................................ 103
65............................................................ 106
66............................................................ 109
67............................................................ 112
68............................................................ 116
69............................................................ 119
70............................................................ 122
71............................................................ 126
72............................................................ 129
73............................................................ 133
74............................................................ 136
75............................................................ 139
76............................................................ 143
------------------------------------------------------------------------
\1\ Height measured without shoes.

Table IV--Women
------------------------------------------------------------------------
Weight
Height (inches) \1\ (pounds)
------------------------------------------------------------------------
58............................................................ 82
59............................................................ 84
60............................................................ 87
61............................................................ 89
62............................................................ 92
63............................................................ 94
64............................................................ 97
65............................................................ 100
66............................................................ 104
67............................................................ 107
68............................................................ 111
69............................................................ 114
70............................................................ 117
71............................................................ 121
72............................................................ 124
73............................................................ 128
------------------------------------------------------------------------
\1\ Height measured without shoes.

6.00 Genito-Urinary System

A. Determination of the presence of chronic renal disease will be
based upon (1) a history, physical examination, and laboratory evidence
of renal disease, and (2) indications of its progressive nature or
laboratory evidence of deterioration of renal function.
B. Nephrotic Syndrome. The medical evidence establishing the
clinical diagnosis must include the description of extent of tissue
edema, including pretibial, periorbital, or presacral edema. The
presence of ascites, pleural effusion, pericardial effusion, and
hydroarthrosis should be described if present. Results of pertinent
laboratory tests must be provided. If a renal biopsy has been performed,
the evidence should include a copy of the report of microscopic
examination of the specimen. Complications such as severe orthostatic
hypotension, recurrent infections or venous thromboses should be
evaluated on the basis of resultant impairment.
C. Hemodialysis, peritioneal dialysis, and kidney transplantation.
When an individual is undergoing periodic dialysis because of chronic
renal disease, severity of impairment is reflected by the renal function
prior to the institution of dialysis.
The amount of function restored and the time required to effect
improvement in an individual treated by renal transplant depend upon
various factors, including adequacy of post transplant renal function,
incidence and severity of renal infection, occurrence of rejection
crisis, the presence of systemic complications (anemia, neunropathy,
etc.) and side effects of corticosteroids or immuno-suppressive agents.
A convalesent period of at least 12 months is required before it can be
reasonably determined whether the individual has reached a point of
stable medical improvement.
D. Evaluate associated disorders and complications according to the
appropriate body system Listing.
6.01 Category of Impairments, Genito-Urinary System
6.02 Impairment of renal function, due to any chronic renal disease
expected to last 12 months (e.g., hypertensive vascular disease, chronic
nephritis, nephrolithiasis, polycystic disease, bilateral
hydronephrosis, etc.) With:
A. Chronic hemodialysis or peritoneal dialysis necessitated by
irreversible renal failure; or
B. Kidney transplant. Consider under a disability for 12 months
following surgery; thereafter, evaluate the residual impairment (see
6.00C); or
C. Persistent elevation of serum creatine in to 4 mg. per deciliter
(100 ml.) or greater or reduction of creatinine clearance to 20 ml. per
minute (29 liters/24 hours) or less, over at least 3 months, with one of
the following:
1. Renal osteodystrophy manifested by severe bone pain and
appropriate radiographic abnormalities (e.g., osteitis fibrosa, marked
osteoporosis, pathologic fractures); or
2. A clinical episode of pericarditis; or
3. Persistent motor or sensory neuropathy; or
4. Intractable pruritus; or
5. Persistent fluid overload syndrome resulting in diastolic
hypertension (110 mm. or above) or signs of vascular congestion; or
6. Persistent anorexia with recent weight loss and current weight
meeting the values in 5.08, Table III or IV; or
7. Persistent hematocrits of 30 percent or less.

[[Page 410]]

6.06 Nephrotic syndrome, with significant anasarca, persistent for
at least 3 months despite prescribed therapy. With:
A. Serum albumin of 3.0 gm. per deciler (100 ml.) or less and
protenuria of 3.5 gm. per 24 hours or greater; or
B. Proteinuria of 10.0 gm. per 24 hours or greater.

7.00 Hemic and Lymphatic System

A. Impairment caused by anemia should be evaluated according to the
ability of the individual to adjust to the reduced oxygen carrying
capacity of the blood. A gradual reduction in red cell mass, even to
very low values, is often well tolerated in individuals with a healthy
cardiovascular system.
B. Chronicity is indicated by persistence of the condition for at
least 3 months. The laboratory findings cited must reflect the values
reported on more than one examination over that 3-month period.
C. Sickle cell disease refers to a chronic hemolytic anemia
associated with sickle cell hemoglobin, either homozygous or in
combination with thalassemia or with another abnormal hemoglobin (such
as C or F).
Appropriate hematologic evidence for sickle cell disease, such as
hemoglobin electrophoresis, must be included. Vasoocclusive or aplastic
episodes should be documented by description of severity, frequency, and
duration.
Major visceral episodes include meningitis, osteomyelitis, pulmonary
infections or infarctions, cerebrovascular accidents, congestive heart
failure, genito-urinary involvement, etc.
D. Coagulation defects. Chronic inherited coagulation disorders must
be documented by appropriate laboratory evidence. Prophylactic therapy
such as with antihemophilic globulin (AHG) concentrate does not in
itself imply severity.
E. Acute leukemia. Initial diagnosis of acute leukemia must be based
upon definitive bone marrow pathologic evidence. Recurrent disease may
be documented by peripheral blood, bone marrow, or cerebrospinal fluid
examination. The pathology report must be included.
The acute phase of chronic myelocytic (granulocytic) leukemia should
be considered under the requirements for acute leukemia.
The criteria in 7.11 contain the designated duration of disability
implicit in the finding of a listed impairment. Following the designated
time period, a documented diagnosis itself is no longer sufficient to
establish a marked impairment. The level of any remaining impairment
must be evaluated on the basis of the medical evidence.
7.01 Category of Impairments, Hemic and Lymphatic System
7.02 Chronic anemia (hematocrit persisting at 30 percent or less
due to any cause). With:
A. Requirement of one or more blood transfusions on an average of at
least once every 2 months; or
B. Evaluation of the resulting impairment under criteria for the
affected body system.
7.05 Sickle cell disease, or one of its variants. With:
A. Documented painful (thrombotic) crises occurring at least three
times during the 5 months prior to adjudication; or
B. Requiring extended hospitalization (beyond emergency care) at
least three times during the 12 months prior to adjudication; or
C. Chronic, severe anemia with persistence of hematocrit of 26
percent or less; or
D. Evaluate the resulting impairment under the criteria for the
affected body system.
7.06 Chronic thrombocytopenia (due to any cause) with platelet
counts repeatedly below 40,000/cubic millimeter. With:
A. At least one spontaneous hemorrhage, requiring transfusion,
within 5 months prior to adjudication; or
B. Intracranial bleeding within 12 months prior to adjudication.
7.07 Hereditary telangiectasia with hemorrhage requiring
transfusion at least three times during the 5 months prior to
adjudication.
7.08 Coagulation defects (hemophilia or a similar disorder) with
spontaneous hemorrhage requiring transfusion at least three times during
the 5 months prior to adjudication.
7.09 Polycythemia vera (with erythrocytosis, splenomegaly, and
leukocytosis or thrombocytosis). Evaluate the resulting impairment under
the criteria for the affected body system.
7.10 Myelofibrosis (myeloproliferative syndrome). With:
A. Chronic anemia. Evaluate according to the criteria of Sec. 7.02;
or
B. Documented recurrent systemic bacterial infections occurring at
least 3 times during the 5 months prior to adjudication; or
C. Intractable bone pain with radiologic evidence of osteosclerosis.
7.11 Acute leukemia. Consider under a disability for 2\1/2\ years
from the time of initial diagnosis.
7.12 Chronic leukemia. Evaluate according to the criteria of 7.02,
7.06, 7.10B, 7.11, 7.17, or 13.06A.
7.13 Lymphomas. Evaluate under the criteria in 13.06A.
7.14 Macroglobulinemia or heavy chain disease, confirmed by serum
or urine protein electrophoresis or immunoelectrophoresias. Evaluate
impairment under criteria for affected body system or under 7.02, 7.06,
or 7.08.
7.15 Chronic granulocytopenia (due to any cause). With both A and
B:
A. Absolute neutrophil counts repeatedly below 1,000 cells/cubic
millimeter; and

[[Page 411]]

B. Documented recurrent systemic bacterial infections occurring at
least 3 times during the 5 months prior to adjudication.
7.16 Myeloma (confirmed by appropriate serum or urine protein
electrophoresis and bone marrow findings). With:
A. Radiologic evidence of bony involvement with intractable bone
pain; or
B. Evidence of renal impairment as described in 6.02; or
C. Hypercalcemia with serum calcium levels persistently greater than
11 mg. per deciliter (100 ml.) for at least 1 month despite prescribed
therapy; or
D. Plasma cells (100 or more cells/cubic millimeter) in the
peripheral blood.
7.17 Aplastic anemias or hematologic malignancies (excluding acute
leukemia): With bone marrow transplantation. Consider under a disability
for 12 months following transplantation; thereafter, evaluate according
to the primary characteristics of the residual impairment.

8.00 Skin

A. Skin lesions may result in a marked, long-lasting impairment if
they involve extensive body areas or critical areas such as the hands or
feet and become resistant to treatment. These lesions must be shown to
have persisted for a sufficient period of time despite therapy for a
reasonable presumption to be made that a marked impairment will last for
a continuous period of at least 12 months. The treatment for some of the
skin diseases listed in this section may require the use of high dosage
of drugs with possible serious side effects; these side effects should
be considered in the overall evaluation of impairment.
B. When skin lesions are associated with systemic disease and where
that is the predominant problems, evaluation should occur according to
the criteria in the appropriate section. Disseminated (systemic) lupus
erythematosus and scleroderma usually involve more than one body system
and should be evaluated under 14.02 and 14.04. Neoplastic skin lesions
should be evaluated under 13.00ff. When skin lesions (including burns)
are associated with contractures or limitation of joint motion, that
impairment should be evaluated under 1.00ff.
8.01 Category of Impairments, Skin
8.02 Exfoliative dermatitis, ichthyosis, ichthyosiform
erythroderma. With extensive lesions not responding to prescribed
treatment.
8.03 Pemphigus, erythema multiforme bullosum, bullous pemphigoid,
dermatitis herpetiformis. With extensive lesions not responding to
prescribed treatment.
8.04 Deep mycotic infections. With extensive fungating, ulcerating
lesions not responding to prescribed treatment.
8.05 Psoriasis, atopic dermatitis, dyshidrosis. With extensive
lesions, including involvement of the hands or feet which impose a
marked limitation of function and which are not responding to prescribed
treatment.
8.06 Hydradenitis suppurative, acne conglobata. With extensive
lesions involving the axillae or perineum not responding to prescribed
medical treatment and not amendable to surgical treatment.

9.00 Endocrine System and Obesity

Cause of impairment. Impairment is caused by overproduction or
underproduction of hormones, resulting in structural 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 under the appropriate
sections.
Long-term massive obesity will usually be associated with disorders
of the musculoskeletal, cardiovascular, peripheral vascular, and
pulmonary systems, and the occurrence of these disorders is the major
cause of disability at the listing level. Extreme obesity results in
restrictions imposed by body weight and the additional restrictions
imposed by disturbances in other body systems.
The weight-bearing criterion in 9.09A refers to the lumbosacral
spine. The cervical and thoracic spines are not considered weight-
bearing.
9.01 Category of Impairments, Endocrine System and Obesity
9.02 Thyroid Disorders. With:
A. Progressive exophthalmos as measured by exophthalmometry; or
B. Evaluate the resulting impairment under the criteria for the
affected body system.
9.03 Hyperparathyroidism. With:
A. Generalized decalcification of bone on X-ray study and elevation
of plasma calcium to 11 mg. per deciliter (100 ml.) or greater; or
B. A resulting impairment. Evaluate according to the criteria in the
affected body system.
9.04 Hypoparathyroidism. With:
A. Severe recurrent tetany; or
B. Recurrent generalized convulsions; or
C. Lenticular cataracts. Evaluate under the criteria in 2.00ff.
9.05 Neurohypophyseal insufficiency (diabetes insipidus). With
urine specific gravity of 1.005 or below, persistent for at least 3
months and recurrent dehydration.
9.06 Hyperfunction of the adrenal cortex. Evaluate the resulting
impairment under the criteria for the affected body system.
9.08 Diabetes mellitus. With:
A. Neuropathy demonstrated by significant and persistent
disorganization of motor function in two extremities resulting in
sustained disturbance of gross and dexterous movements, or gait and
station (see 11.00C); or

[[Page 412]]

B. Acidosis occurring at least on the average of once every 2 months
documented by appropriate blood chemical tests (pH or pCO2 or
bicarbonate levels); or
C. Amputation at, or above, the tarsal region due to diabetic
necrosis or peripheral arterial disease; or
D. Retinitis proliferans; evaluate the visual impairment under the
criteria in 2.02, 2.03, or 2.04.
9.09 Obesity. Weight equal to or greater than the values specified
in Table I for males, Table II for females (100 percent above desired
level), and one of the following:
A. History of pain and limitation of motion in any weight-bearing
joint or the lumbosacral spine (on physical examination) associated with
findings on medically acceptable imaging techniques of arthritis in the
affected joint or lumbosacral spine; or
B. Hypertension with diastolic blood pressure persistently in excess
of 100 mm. Hg measured with appropriate size cuff; or
C. History of congestive heart failure manifested by past evidence
of vascular congestion such as hepatomegaly, peripheral or pulmonary
edema; or
D. Chronic venous insufficiency with superficial varicosities in a
lower extremity with pain on weight bearing and persistent edema; or
E. Respiratory disease with total forced vital capacity equal to or
less than 2.0 L. or a level of hypoxemia at rest equal to or less than
the values specified in Table III-A or III-B or III-C.

Table I.--Men
[Metric]
------------------------------------------------------------------------
Weight
Height without shoes (centimeters) (kilograms)
------------------------------------------------------------------------
152....................................................... 112
155....................................................... 115
157....................................................... 117
160....................................................... 120
163....................................................... 123
165....................................................... 125
168....................................................... 129
170....................................................... 134
173....................................................... 137
175....................................................... 141
178....................................................... 145
180....................................................... 149
183....................................................... 153
185....................................................... 157
188....................................................... 162
190....................................................... 165
193....................................................... 170
------------------------------------------------------------------------

Table I.--Men
------------------------------------------------------------------------
Weight
Height without shoes (inches) (pounds)
------------------------------------------------------------------------
60........................................................ 246
61........................................................ 252
62........................................................ 258
63........................................................ 264
64........................................................ 270
65........................................................ 276
66........................................................ 284
67........................................................ 294
68........................................................ 302
69........................................................ 310
70........................................................ 318
71........................................................ 328
72........................................................ 336
73........................................................ 346
74........................................................ 356
75........................................................ 364
76........................................................ 374
------------------------------------------------------------------------

Table II.--Women
[Metric]
------------------------------------------------------------------------
Weight
Height without shoes (centimeters) (kilograms)
------------------------------------------------------------------------
142....................................................... 95
145....................................................... 96
147....................................................... 99
150....................................................... 102
152....................................................... 105
155....................................................... 107
157....................................................... 110
160....................................................... 114
163....................................................... 117
165....................................................... 121
168....................................................... 125
170....................................................... 128
173....................................................... 132
175....................................................... 135
178....................................................... 139
180....................................................... 143
183....................................................... 146
------------------------------------------------------------------------

Table II.--Women
------------------------------------------------------------------------
Weight
Height without shoes (inches) (pounds)
------------------------------------------------------------------------
56........................................................ 208
57........................................................ 212
58........................................................ 218
59........................................................ 224
60........................................................ 230
61........................................................ 236
62........................................................ 242
63........................................................ 250
64........................................................ 258
65........................................................ 266
66........................................................ 274
67........................................................ 282
68........................................................ 290
69........................................................ 298
70........................................................ 306
71........................................................ 314
72........................................................ 322
------------------------------------------------------------------------

[[Page 413]]

Table III--A
[Applicable at test sites less than 3,000 feet above sea level]
------------------------------------------------------------------------
Arterial
PO2 equal
Arterial PCO2 (mm. Hg) and to or
less than
(mm. Hg)
------------------------------------------------------------------------
30 or below.................................................. 65
31........................................................... 64
32........................................................... 63
33........................................................... 62
34........................................................... 61
35........................................................... 60
36........................................................... 59
37........................................................... 58
38........................................................... 57
39........................................................... 56
40 or above.................................................. 55
------------------------------------------------------------------------

Table III--B
[Applicable at test sites 3,000 through 6,000 feet above sea level]
------------------------------------------------------------------------
Arterial
PO2 equal
Arterial PCO2 (mm. Hg) and to or
less than
(mm. Hg)
------------------------------------------------------------------------
30 or below.................................................. 60
31........................................................... 59
32........................................................... 58
33........................................................... 57
34........................................................... 56
35........................................................... 55
36........................................................... 54
37........................................................... 53
38........................................................... 52
39........................................................... 51
40 or above.................................................. 50
------------------------------------------------------------------------

Table III--C
[Applicable at test sites over 6,000 feet above sea level]
------------------------------------------------------------------------
Arterial
PO2 equal
Arterial PCO2 (mm. Hg) and to or
less than
(mm. Hg)
------------------------------------------------------------------------
30 or below.................................................. 55
31........................................................... 54
32........................................................... 53
33........................................................... 52
34........................................................... 51
35........................................................... 50
36........................................................... 49
37........................................................... 48
38........................................................... 47
39........................................................... 46
40 or above.................................................. 45
------------------------------------------------------------------------

10.00 [Reserved]

11.00 Neurological

A. Convulsive disorders. In convulsive disorders, regardless of
etiology degree of impairment will be determined according to type,
frequency, duration, and sequelae of seizures. At least one detailed
description of a typical seizure is required. Such description includes
the presence or absence of aura, tongue bites, sphincter control,
injuries associated with the attack, and postictal phenomena. The
reporting physician should indicate the extent to which description of
seizures reflects his own observations and the source of ancillary
information. Testimony of persons other than the claimant is essential
for description of type and frequency of seizures if professional
observation is not available.
Documentation of epilepsy should include at least one
electroencephalogram (EEG).
Under 11.02 and 11.03, the criteria can be applied only if the
impairment persists despite the fact that the individual is following
prescribed anticonvulsive treatment. Adherence to prescribed
anticonvulsive therapy can ordinarily be determined from objective
clinical findings in the report of the physician currently providing
treatment for epilepsy. Determination of blood levels of phenytoin
sodium or other anticonvulsive drugs may serve to indicate whether the
prescribed medication is being taken. When seizures are occurrring at
the frequency stated in 11.02 or 11.03, evalution of the severity of the
impairment must include consideration of the serum drug levels. Should
serum drug levels appear therapeutically inadequate, consideration
should be given as to whether this is caused by individual idiosyncrasy
in absorption of metabolism of the drug. Blood drug levels should be
evaluated in conjunction with all the other evidence to determine the
extent of compliance. When the reported blood drug levels are low,
therefore, the information obtained from the treating source should
include the physician's statement as to why the levels are low and the
results of any relevant diagnostic studies concerning the blood levels.
Where adequate seizure control is obtained only with unusually large
doses, the possibility of impairment resulting from the side effects of
this medication must be also assessed. Where documentation shows that
use of alcohol or drugs affects adherence to prescribed therapy or may
play a part in the precipitation of seizures, this must also be
considered in the overall assessment of impairment level.
B. Brain tumors. The diagnosis of malignant brain tumors must be
established, and the persistence of the tumor should be evaluated, under
the criteria described in 13.00B and C for neoplastic disease.
In histologically malignant tumors, the pathological diagnosis alone
will be the decisive criterion for severity and expected duration (see
11.05A). For other tumors of the brain, the severity and duration of the
impairment will be determined on the basis of symptoms, signs, and
pertinent laboratory findings (11.05B).

[[Page 414]]

C. Persistent disorganization of motor function in the form of
paresis or paralysis, tremor or other involuntary movements, ataxia and
sensory distrubances (any or all of which may be due to cerebral
cerbellar, brain stem, spinal cord, or peripheral nerve dysfunction)
which occur singly or in various combination, frequently provides the
sole or partial basis for decision in cases of neurological impairment.
The assessment of impairment depends on the degree of interference with
locomotion and/or interference with the use of fingers, hands, and arms.
D. In conditions which are episodic in character, such as multiple
sclerosis or myasthenia gravis, consideration should be given to
frequency and duration of exacerbations, length of remissions, and
permanent residuals.
E. Multiple sclerosis. The major criteria for evaluating impairment
caused by multiple sclerosis are discussed in listing 11.09. Paragraph A
provides criteria for evaluating disorganization of motor function and
gives reference to 11.04B (11.04B then refers to 11.00C). Paragraph B
provides references to other listings for evaluating visual or mental
impairments caused by multiple sclerosis. Paragraph C provides criteria
for evaluating the impairment of individuals who do not have muscle
weakness or other significant disorganization of motor function at rest,
but who do develop muscle weakness on activity as a result of fatigue.
Use of the criteria in 11.09C is dependent upon (1) documenting a
diagnosis of multiple sclerosis, (2) obtaining a description of fatigue
considered to be characteristic of multiple sclerosis, and (3) obtaining
evidence that the system has actually become fatigued. The evaluation of
the magnitude of the impairment must consider the degree of exercise and
the severity of the resulting muscle weakness.
The criteria in 11.09C deals with motor abnormalities which occur on
activity. If the disorganization of motor function is present at rest,
paragraph A must be used, taking into account any further increase in
muscle weakness resulting from activity.
Sensory abnormalities may occur, particularly involving central
visual acuity. The decrease in visual acuity may occur after brief
attempts at activity involving near vision, such as reading. This
decrease in visual acuity may not persist when the specific activity is
terminated, as with rest, but is predictably reproduced with resumption
of the activity. The impairment of central visual acuity in these cases
should be evaluated under the criteria in listing 2.02, taking into
account the fact that the decrease in visual acuity will wax and wane.
Clarification of the evidence regarding central nervous system
dysfunction responsible for the symptoms may require supporting
technical evidence of functional impairment such as evoked response
tests during exercise.
11.01 Category of Impairments, Neurological
11.02 Epilepsy--major motor seizures, (grand mal or psychomotor),
documented by EEG and by detailed description of a typical seizure
pattern, including all associated phenomena; occurring more frequently
than once a month, in spite of at least 3 months of prescribed
treatment. With:
A. Daytime episodes (loss of consciousness and convulsive seizures)
or
B. Nocturnal episodes manifesting residuals which interfere
significantly with activity during the day.
11.03 Epilepsy--Minor motor seizures (petit mal, psychomotor, or
focal), documented by EEG and by detailed description of a typical
seizure pattern, including all associated phenomena; occurring more
frequently than once weekly in spite of at least 3 months of prescribed
treatment. With alteration of awareness or loss of consciousness and
transient postictal manifestations of unconventional behavior or
significant interference with activity during the day.
11.04 Central nervous system vascular accident. With one of the
following more than 3 months post-vascular accident:
A. Sensory or motor aphasia resulting in ineffective speech or
communication; or
B. Significant and persistent disorganization of motor function in
two extremities, resulting in sustained disturbance of gross and
dexterous movements, or gait and station (see 11.00C).
11.05 Brain tumors.
A. Malignant gliomas (astrocytoma--grades III and IV, glioblastoma
multiforme), medulloblastoma, ependymoblastoma, or primary sarcoma; or
B. Astrocytoma (grades I and II), meningioma, pituitary tumors,
oligodendroglioma, ependymoma, clivus chordoma, and benign tumors.
Evaluate under 11.02, 11.03, 11.04 A, or B, or 12.02.
11.06 Parkinsonian syndrome with the following signs: Significant
rigidity, brady kinesia, or tremor in two extremities, which, singly or
in combination, result in sustained disturbance of gross and dexterous
movements, or gait and station.
11.07 Cerebral palsy. With:
A. IQ of 70 or less; or
B. Abnormal behavior patterns, such as destructiveness or emotional
instability: or
C. Significant interference in communication due to speech, hearing,
or visual defect; or
D. Disorganization of motor function as described in 11.04B.
11.08 Spinal cord or nerve root lesions, due to any cause with
disorganization of motor function as described in 11.04B.
11.09 Multiple sclerosis. With:

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A. Disorganization of motor function as described in 11.04B; or
B. Visual or mental impairment as described under the criteria in
2.02, 2.03, 2.04, or 12.02; or
C. Significant, reproducible fatigue of motor function with
substantial muscle weakness on repetitive activity, demonstrated on
physical examination, resulting from neurological dysfunction in areas
of the central nervous system known to be pathologically involved by the
multiple sclerosis process.
11.10 Amyotrophic lateral sclerosis. With:
A. Significant bulbar signs; or
B. Disorganization of motor function as described in 11.04B.
11.11 Anterior poliomyelitis. With:
A. Persistent difficulty with swallowing or breathing; or
B. Unintelligible speech; or
C. Disorganization of motor function as described in 11.04B.
11.12 Myasthenia gravis. With:
A. Significant difficulty with speaking, swallowing, or breathing
while on prescribed therapy; or
B. Significant motor weakness of muscles of extremities on
repetitive activity against resistance while on prescribed therapy.
11.13 Muscular dystrophy with disorganization of motor function as
described in 11.04B.
11.14 Peripheral neuropathies.
With disorganization of motor function as described in 11.04B, in
spite of prescribed treatment.
11.15 Tabes dorsalis.
With:
A. Tabetic crises occurring more frequently than once monthly; or
B. Unsteady, broad-based or ataxic gait causing significant
restriction of mobility substantiated by appropriate posterior column
signs.
11.16 Subacute combined cord degeneration (pernicious anemia) with
disorganization of motor function as decribed in 11.04B or 11.15B, not
significantly improved by prescribed treatment.
11.17 Degenerative disease not elsewhere such as Huntington's
chorea, Friedreich's ataxia, and spino-cerebellar degeneration. With:
A. Disorganization of motor function as described in 11.04B or
11.15B; or
B. Chronic brain syndrome. Evaluate under 12.02.
11.18 Cerebral trauma:
Evaluate under the provisions of 11.02, 11.03, 11.04 and 12.02, as
applicable.
11.19 Syringomyelia.
With:
A. Significant bulbar signs; or
B. Disorganization of motor function as described in 11.04B.

12.00 Mental Disorders

The mental disorders listings in 12.00 of the Listing of Impairments
will no longer be effective on August 28, 1997, unless extended by the
Commissioner or revised and promulgated again.
A. Introduction: The evaluation of disability on the basis of mental
disorders requires the documentation of a medically determinable
impairment(s) as well as consideration of the degree of limitation such
impairment(s) may impose on the individual's ability to work and whether
these limitations have lasted or are expected to last for a continuous
period of at least 12 months. The listings for mental disorders are
arranged in eight diagnostic categories: organic mental disorders
(12.02); schizophrenic, paranoid and other psychotic disorders (12.03);
affective disorders (12.04); mental retardation and autism (12.05);
anxiety related disorders (12.06); somatoform disorders (12.07);
personality disorders (12.08); and substance addiction disorders
(12.09). Each diagnostic group, except listings 12.05 and 12.09,
consists of a set of clinical findings (paragraph A criteria), one or
more of which must be met, and which, if met, lead to a test of
functional restrictions (paragraph B criteria), two or three of which
must also be met. There are additional considerations (paragraph C
criteria) in listings 12.03 and 12.06, discussed therein.
The purpose of including the criteria in paragraph A of the listings
for mental disorders is to medically substantiate the presence of a
mental disorder. Specific signs and symptoms under any of the listings
12.02 through 12.09 cannot be considered in isolation from the
description of the mental disorder contained at the beginning of each
listing category. Impairments should be analyzed or reviewed under the
mental category(ies) which is supported by the individual's clinical
findings.
The purpose of including the criteria in paragraphs B and C of the
listings for mental disorders is to describe those functional
limitations associated with mental disorders which are incompatible with
the ability to work. The restrictions listed in paragraphs B and C must
be the result of the mental disorder which is manifested by the clinical
findings outlined in paragraph A. The criteria included in paragraphs B
and C of the listings for mental disorders have been chosen because they
represent functional areas deemed essential to work. An individual who
is severely limited in these areas as the result of an impairment
identified in paragraph A is presumed to be unable to work.
The structure of the listing for substance addiction disorders,
listing 12.09, is different from that for the other mental disorder
listings. Listing 12.09 is structured as a reference listing; that is,
it will only serve to

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indicate which of the other listed mental or physical impairments must
be used to evaluate the behavioral or physical changes resulting from
regular use of addictive substances.
The listings for mental disorders are so constructed that an
individual meeting or equaling the criteria could not reasonably be
expected to engage in gainful work activity.
Individuals who have an impairment with a level of severity which
does not meet the criteria of the listings for mental disorders may or
may not have the residual functional capacity (RFC) which would enable
them to engage in substantial gainful work activity. The determination
of mental RFC is crucial to the evaluation of an individual's capacity
to engage in substantial gainful work activity when the criteria of the
listings for mental disorders are not met or equaled but the impairment
is nevertheless severe.
RFC may be defined as a multidimensional description of the work-
related abilities which an individual retains in spite of medical
impairments. RFC complements the criteria in paragraphs B and C of the
listings for mental disorders by requiring consideration of an expanded
list of work-related capacities which may be impaired by mental disorder
when the impairment is severe but does not meet or equal a listed mental
disorder.
B. Need for Medical Evidence: The existence of a medically
determinable impairment of the required duration must be established by
medical evidence consisting of clinical signs, symptoms and/or
laboratory or psychological test findings. These findings may be
intermittent or persistent depending on the nature of the disorder.
Clinical signs are medically demonstrable phenomena which reflect
specific abnormalities of behavior, affect, thought, memory,
orientation, or contact with reality. These signs are typically assessed
by a psychiatrist or psychologist and/or documented by psychological
tests. Symptoms are complaints presented by the individual. Signs and
symptoms generally cluster together to constitute recognizable clinical
syndromes (mental disorders). Both symptoms and signs which are part of
any diagnosed mental disorder must be considered in evaluating severity.
C. Assessment of Severity: For mental disorders, severity is
assessed in terms of the functional limitations imposed by the
impairment. Functional limitations are assessed using the criteria in
paragraph B of the listings for mental disorders (descriptions of
restrictions of activities of daily living; social functioning;
concentration, persistence, or pace; and ability to tolerate increased
mental demands associated with competitive work). Where ``marked'' is
used as a standard for measuring the degree of limitation, it means more
than moderate, but less than extreme. A marked limitation may arise when
several activities or functions are impaired or even when only one is
impaired, so long as the degree of limitation is such as to seriously
interfere with the ability to function independently, appropriately and
effectively. Four areas are considered.
1. Activities of daily living include adaptive activities such as
cleaning, shopping, cooking, taking public transportation, paying bills,
maintaining a residence, caring appropriately for one's grooming and
hygiene, using telephones and directories, using a post office, etc. In
the context of the individual's overall situation, the quality of these
activities is judged by their independence, appropriateness and
effectiveness. It is necessary to define the extent to which the
individual is capable of initiating and participating in activities
independent of supervision or direction.
``Marked'' is not the number of activities which are restricted but
the overall degree of restriction or combination of restrictions which
must be judged. For example, a person who is able to cook and clean
might still have marked restrictions of daily activities if the person
were too fearful to leave the immediate environment of home and
neighborhood, hampering the person's ability to obtain treatment or to
travel away from the immediate living environment.
2. Social functioning refers to an individual's capacity to interact
appropriately and communicate effectively with other individuals. Social
functioning includes the ability to get along with others, e.g., family
members, friends, neighbors, grocery clerks, landlords, bus drivers,
etc. Impaired social functioning may be demonstrated by a history of
altercations, evictions, firings, fear of strangers, avoidance of
interpersonal relationships, social isolation, etc. Strength in social
functioning may be documented by an individual's ability to initiate
social contacts with others, communicate clearly with others, interact
and actively participate in group activities, etc. Cooperative
behaviors, consideration for others, awareness of others' feelings, and
social maturity also need to be considered. Social functioning in work
situations may involve interactions with the public, responding
appropriately to persons in authority, e.g., supervisors, or cooperative
behaviors involving coworkers.
``Marked'' is not the number of areas in which social functioning is
impaired, but the overall degree of interference in a particular area or
combination of areas of functioning. For example, a person who is highly
antagonistic, uncooperative or hostile but is tolerated by local
storekeepers may nevertheless have marked restrictions in social
functioning because that behavior is not acceptable in other social
contexts.
3. Concentration, persistence and pace refer to the ability to
sustain focused attention

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sufficiently long to permit the timely completion of tasks commonly
found in work settings. In activities of daily living, concentration may
be reflected in terms of ability to complete tasks in everyday household
routines. Deficiencies in concentration, persistence and pace are best
observed in work and work-like settings. Major impairment in this area
can often be assessed through direct psychiatric examination and/or
psychological testing, although mental status examination or
psychological test data alone should not be used to accurately describe
concentration and sustained ability to adequately perform work-like
tasks. On mental status examinations, concentration is assessed by tasks
such as having the individual subtract serial sevens from 100. In
psychological tests of intelligence or memory, concentration is assessed
through tasks requiring short-term memory or through tasks that must be
completed within established time limits. In work evaluations,
concentration, persistence, and pace are assessed through such tasks as
filing index cards, locating telephone numbers, or disassembling and
reassembling objects. Strengths and weaknesses in areas of concentration
can be discussed in terms of frequency of errors, time it takes to
complete the task, and extent to which assistance is required to
complete the task.
4. Deterioration or decompensation in work or work-like settings
refers to repeated failure to adapt to stressful circumstances which
cause the individual either to withdraw from that situation or to
experience exacerbation of signs and symptoms (i.e., decompensation)
with an accompanying difficulty in maintaining activities of daily
living, social relationships, and/or maintaining concentration,
persistence, or pace (i.e., deterioration which may include
deterioration of adaptive behaviors). Stresses common to the work
environment include decisions, attendance, schedules, completing tasks,
interactions with supervisors, interactions with peers, etc.
D. Documentation: The presence of a mental disorder should be
documented primarily on the basis of reports from individual providers,
such as psychiatrists and psychologists, and facilities such as
hospitals and clinics. Adequate descriptions of functional limitations
must be obtained from these or other sources which may include programs
and facilities where the individual has been observed over a
considerable period of time.
Information from both medical and nonmedical sources may be used to
obtain detailed descriptions of the individual's activities of daily
living; social functioning; concentration, persistance and pace; or
ability to tolerate increased mental demands (stress). This information
can be provided by programs such as community mental health centers, day
care centers, sheltered workshops, etc. It can also be provided by
others, including family members, who have knowledge of the individual's
functioning. In some cases descriptions of activities of daily living or
social functioning given by individuals or treating sources may be
insufficiently detailed and/or may be in conflict with the clinical
picture otherwise observed or described in the examinations or reports.
It is necessary to resolve any inconsistencies or gaps that may exist in
order to obtain a proper understanding of the individual's functional
restrictions.
An individual's level of functioning may vary considerably over
time. The level of functioning at a specific time may seem relatively
adequate or, conversely, rather poor. Proper evaluation of the
impairment must take any variations in level of functioning into account
in arriving at a determination of impairment severity over time. Thus,
it is vital to obtain evidence from relevant sources over a sufficiently
long period prior to the date of adjudication in order to establish the
individual's impairment severity. This evidence should include treatment
notes, hospital discharge summaries, and work evaluation or
rehabilitation progress notes if these are available.
Some individuals may have attempted to work or may actually have
worked during the period of time pertinent to the determination of
disability. This may have been an independent attempt at work, or it may
have been in conjunction with a community mental health or other
sheltered program which may have been of either short or long duration.
Information concerning the individual's behavior during any attempt to
work and the circumstances surrounding termination of the work effort
are particularly useful in determining the individual's ability or
inability to function in a work setting.
The results of well-standardized psychological tests such as the
Wechsler Adult Intelligence Scale (WAIS), the Minnesota Multiphasic
Personality Inventory (MMPI), the Rorschach, and the Thematic
Apperception Test (TAT), may be useful in establishing the existence of
a mental disorder. For example, the WAIS is useful in establishing
mental retardation, and the MMPI, Rorschach, and TAT may provide data
supporting several other diagnoses. Broad-based neuropsychological
assessments using, for example, the Halstead-Reitan or the Luria-
Nebraska batteries may be useful in determining brain function
deficiencies, particularly in cases involving subtle findings such as
may be seen in traumatic brain injury. In addition, the process of
taking a standardized test requires concentration, persistence and pace;
performance on such tests may provide useful data. Test results should,
therefore, include both the objective data and a narrative description
of clinical findings. Narrative reports of intellectual assessment
should include a discussion of whether

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or not obtained IQ scores are considered valid and consistent with the
individual's developmental history and degree of functional restriction.
In cases involving impaired intellectual functioning, a standardized
intelligence test, e.g., the WAIS, should be administered and
interpreted by a psychologist or psychiatrist qualified by training and
experience to perform such an evaluation. In special circumstances,
nonverbal measures, such as the Raven Progressive Matrices, the Leiter
international scale, or the Arthur adaptation of the Leiter may be
substituted.
Identical IQ scores obtained from different tests do not always
reflect a similar degree of intellectual functioning. In this
connection, it must be noted that on the WAIS, for example, IQs of 70
and below are characteristic of approximately the lowest 2 percent of
the general population. In instances where other tests are administered,
it would be necessary to convert the IQ to the corresponding percentile
rank in the general population in order to determine the actual degree
of impairment reflected by those IQ scores.
In cases where more than one IQ is customarily derived from the test
administered, i.e., where verbal, performance, and full-scale IQs are
provided as on the WAIS, the lowest of these is used in conjunction with
listing 12.05.
In cases where the nature of the individual's intellectual
impairment is such that standard intelligence tests, as described above,
are precluded, medical reports specifically describing the level of
intellectual, social, and physical function should be obtained. Actual
observations by Social Security Administration or State agency
personnel, reports from educational institutions and information
furnished by public welfare agencies or other reliable objective sources
should be considered as additional evidence.
E. Chronic Mental Impairments: Particular problems are often
involved in evaluating mental impairments in individuals who have long
histories of repeated hospitalizations or prolonged outpatient care with
supportive therapy and medication. Individuals with chronic psychotic
disorders commonly have their lives structured in such a way as to
minimize stress and reduce their signs and symptoms. Such individuals
may be much more impaired for work than their signs and symptoms would
indicate. The results of a single examination may not adequately
describe these individuals' sustained ability to function. It is,
therefore, vital to review all pertinent information relative to the
individual's condition, especially at times of increased stress. It is
mandatory to attempt to obtain adequate descriptive information from all
sources which have treated the individual either currently or in the
time period relevant to the decision.
F. Effects of Structured Settings: Particularly in cases involving
chronic mental disorders, overt symptomatology may be controlled or
attenuated by psychosocial factors such as placement in a hospital,
board and care facility, or other environment that provides similar
structure. Highly structured and supportive settings may greatly reduce
the mental demands placed on an individual. With lowered mental demands,
overt signs and symptoms of the underlying mental disorder may be
minimized. At the same time, however, the individual's ability to
function outside of such a structured and/or supportive setting may not
have changed. An evaluation of individuals whose symptomatology is
controlled or attenuated by psychosocial factors must consider the
ability of the individual to function outside of such highly structured
settings. (For these reasons the paragraph C criteria were added to
Listings 12.03 and 12.06.)
G. Effects of Medication: Attention must be given to the effect of
medication on the individual's signs, symptoms and ability to function.
While psychotropic medications may control certain primary
manifestations of a mental disorder, e.g., hallucinations, such
treatment may or may not affect the functional limitations imposed by
the mental disorder. In cases where overt symptomatology is attenuated
by the psychotropic medications, particular attention must be focused on
the functional restrictions which may persist. These functional
restrictions are also to be used as the measure of impairment severity.
(See the paragraph C criteria in Listings 12.03 and 12.06.)
Neuroleptics, the medicines used in the treatment of some mental
illnesses, may cause drowsiness, blunted affect, or other side effects
involving other body systems. Such side effects must be considered in
evaluating overall impairment severity. Where adverse effects of
medications contribute to the impairment severity and the impairment
does not meet or equal the listings but is nonetheless severe, such
adverse effects must be considered in the assessment of the mental
residual functional capacity.
H. Effect of Treatment: It must be remembered that with adequate
treatment some individuals suffering with chronic mental disorders not
only have their symptoms and signs ameliorated but also return to a
level of function close to that of their premorbid status. Our
discussion here in 12.00H has been designed to reflect the fact that
present day treatment of a mentally impaired individual may or may not
assist in the achievement of an adequate level of adaptation required in
the work place. (See the paragraph C criteria in Listings 12.03 and
12.06.)
I. Technique for Reviewing the Evidence in Mental Disorders Claims
to Determine Level of Impairment Severity: A special technique has been
developed to ensure that all evidence

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needed for the evaluation of impairment severity in claims involving
mental impairment is obtained, considered and properly evaluated. This
technique, which is used in connection with the sequential evaluation
process, is explained in Sec. 404.1520a and Sec. 416.920a.
12.01 Category of Impairments-Mental
12.02 Organic Mental Disorders: Psychological or behaviorial
abnormalities associated with a dysfunction of the brain. History and
physical examination or laboratory tests demonstrate the presence of a
specific organic factor judged to be etiologically related to the
abnormal mental state and loss of previously acquired functional
abilities.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Demonstration of a loss of specific cognitive abilities or
affective changes and the medically documented persistence of at least
one of the following:
1. Disorientation to time and place; or
2. Memory impairment, either short-term (inability to learn new
information), intermediate, or long-term (inability to remember
information that was known sometime in the past); or
3. Perceptual or thinking disturbances (e.g., hallucinations,
delusions); or
4. Change in personality; or
5. Disturbance in mood; or
6. Emotional lability (e.g., explosive temper outbursts, sudden
crying, etc.) and impairment in impulse control; or
7. Loss of measured intellectual ability of at least 15 I.Q. points
from premorbid levels or overall impairment index clearly within the
severely impaired range on neuropsychological testing, e.g., the Luria-
Nebraska, Halstead-Reitan, etc.;
AND

B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Deficiencies of concentration, persistence or pace resulting in
frequent failure to complete tasks in a timely manner (in work settings
or elsewhere); or
4. Repeated episodes of deterioration or decompensation in work or
work-like settings which cause the individual to withdraw from that
situation or to experience exacerbation of signs and symptoms (which may
include deterioration of adaptive behaviors).
12.03 Schizophrenic, Paranoid and Other Psychotic Disorders:
Characterized by the onset of psychotic features with deterioration from
a previous level of functioning.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied, or when the requirements in
C are satisfied.
A. Medically documented persistence, either continuous or
intermittent, of one or more of the following:
1. Delusions or hallucinations; or
2. Catatonic or other grossly disorganized behavior; or
3. Incoherence, loosening of associations, illogical thinking, or
poverty of content of speech if associated with one of the following:
a. Blunt affect; or
b. Flat affect; or
c. Inappropriate affect;

4. Emotional withdrawal and/or isolation;

AND

C. Medically documented history of one or more episodes of acute
symptoms, signs and functional limitations which at the time met the
requirements in A and B of this listing, although these symptoms or
signs are currently attenuated by medication or psychosocial support,
and one of the following:
1. Repeated episodes of deterioration or decompensation in
situations which cause the individual to withdraw from that situation or
to experience exacerbation of signs or symptoms (which may include
deterioration of adaptive behaviors); or
2. Documented current history of two or more years of inability to
function outside of a highly supportive living situation.
12.04 Affective Disorders: Characterized by a disturbance of mood,
accompanied by a full or partial manic or depressive syndrome. Mood
refers to a prolonged emotion that colors the whole psychic life; it
generally involves either depression or elation.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented persistence, either continuous or
intermittent, of one of the following:
1. Depressive syndrome characterized by at least four of the
following:

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a. Anhedonia or pervasive loss of interest in almost all activites;
or
b. Appetite disturbance with change in weight; or
c. Sleep disturbance; or
d. Psychomotor agitation or retardation; or
e. Decreased energy; or
f. Feelings of guilt or worthlessness; or
g. Difficulty concentrating or thinking; or
h. Thoughts of suicide; or
i. Hallucinations, delusions, or paranoid thinking; or
2. Manic syndrome characterized by at least three of the following:
a. Hyperactivity; or
b. Pressure of speech; or
c. Flight of ideas; or
d. Inflated self-esteem; or
e. Decreased need for sleep; or
f. Easy distractability; or
g. Involvement in activities that have a high probability of painful
consequences which are not recognized; or
h. Hallucinations, delusions or paranoid thinking;

3. Bipolar syndrome with a history of episodic periods manifested by
the full symptomatic picture of both manic and depressive syndromes (and
currently characterized by either or both syndromes);

AND

B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Deficiencies of concentration, persistence or pace resulting in
frequent failure to complete tasks in a timely manner (in work settings
or elsewhere); or
4. Repeated episodes of deterioration or decompensation in work or
work-like settings which cause the individual to withdraw from that
situation or to experience exacerbation of signs and symptoms (which may
include deterioration of adaptive behaviors).
12.05 Mental Retardation and Autism: Mental retardation refers to a
significantly subaverage general intellectual functioning with deficits
in adaptive behavior initially manifested during the developmental
period (before age 22). (Note: The scores specified below refer to those
obtained on the WAIS, and are used only for reference purposes. Scores
obtained on other standardized and individually administered tests are
acceptable, but the numerical values obtained must indicate a similar
level of intellectual functioning.) Autism is a pervasive developmental
disorder characterized by social and significant communication deficits
originating in the developmental period.
The required level of severity for this disorder is met when the
requirements in A, B, C, or D are satisfied.
A. Mental incapacity evidenced by dependence upon others for
personal needs (e.g., toileting, eating, dressing, or bathing) and
inability to follow directions, such that the use of standardized
measures of intellectual functioning is precluded;

B. A valid verbal, performance, or full scale IQ of 59 or less;

C. A valid verbal, performance, or full scale IQ of 60 through 70
and a physical or other mental impairment imposing additional and
significant work-related limitation of function;

D. A valid verbal, performance, or full scale IQ of 60 through 70,
or in the case of autism, gross deficits of social and communicative
skills, with either condition resulting in two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Deficiencies of concentration, persistence or pace resulting in
frequent failure to complete tasks in a timely manner (in work settings
or eleswhere); or
4. Repeated episodes of deterioration or decompensation in work or
work-like settings which cause the individual to withdraw from that
situation or to experience exacerbation of signs and symptoms (which may
include deterioration of adaptive behaviors).
12.06 Anxiety Related Disorders: In these disorders anxiety is
either the predominant disturbance or it is experienced if the
individual attempts to master symptoms; for example, confronting the
dreaded object or situation in a phobic disorder or resisting the
obsessions or compulsions in obsessive compulsive disorders.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied, or when the requirements in
both A and C are satisfied.
A. Medically documented findings of at least one of the following:
1. Generalized persistent anxiety accompanied by three out of four
of the following signs or symptoms:
a. Motor tension; or
b. Autonomic hyperactivity; or
c. Apprehensive expectation; or
d. Vigilance and scanning;

2. A persistent irrational fear of a specific object, activity, or
situation which results in a compelling desire to avoid the dreaded
object, activity, or situation; or

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3. Recurrent severe panic attacks manifested by a sudden
unpredictable onset of intense apprehension, fear, terror and sense of
impending doom occurring on the average of at least once a week; or
4. Recurrent obsessions or compulsions which are a source of marked
distress; or
5. Recurrent and intrusive recollections of a traumatic experience,
which are a source of marked distress;

AND

C. Resulting in complete inability to function independently outside
the area of one's home.
12.07 Somatoform Disorders: Physical symptoms for which there are
no demonstrable organic findings or known physiological mechanisms.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented by evidence of one of the following:
1. A history of multiple physical symptoms of several years
duration, beginning before age 30, that have caused the individual to
take medicine frequently, see a physician often and alter life patterns
significantly; or
2. Persistent nonorganic disturbance of one of the following:
a. Vision; or
b. Speech; or
c. Hearing; or
d. Use of a limb; or
e. Movement and its control (e.g., coordination disturbance,
psychogenic seizures, akinesia, dyskinesia; or
f. Sensation (e.g., diminished or heightened).
3. Unrealistic interpretation of physical signs or sensations
associated with the preoccupation or belief that one has a serious
disease or injury;

AND

B. Resulting in three of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Deficiencies of concentration, persistence or pace resulting in
frequent failure to complete tasks in a timely manner (in work settings
or elsewhere); or
4. Repeated episodes of deterioration or decompensation in work or
work-like settings which cause the individual to withdraw from that
situation or to experience exacerbation of signs and symptoms (which may
include deterioration of adaptive behavior).
12.08 Personality Disorders: A personality disorder exists when
personality traits are inflexible and maladaptive and cause either
significant impairment in social or occupational functioning or
subjective distress. Characteristic features are typical of the
individual's long-term functioning and are not limited to discrete
episodes of illness.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Deeply ingrained, maladaptive patterns of behavior associated
with one of the following:
1. Seclusiveness or autistic thinking; or
2. Pathologically inappropriate suspiciousness or hostility; or
3. Oddities of thought, perception, speech and behavior; or
4. Persistent disturbances of mood or affect; or
5. Pathological dependence, passivity, or aggressivity; or
6. Intense and unstable interpersonal relationships and impulsive
and damaging behavior;

AND

B. Resulting in three of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Deficiencies of concentration, persistence or pace resulting in
frequent failure to complete tasks in a timely manner (in work settings
or elsewhere); or
4. Repeated episodes of deterioration or decompensation in work or
work-like settings which cause the individual to withdraw from that
situation or to experience exacerbation of signs and symptoms (which may
include deterioration of adaptive behaviors).
12.09 Substance Addiction Disorders: Behavioral changes or physical
changes associated with the regular use of substances that affect the
central nervous system.
The required level of severity for these disorders is met when the
requirements in any of the following (A through I) are satisfied.
A. Organic mental disorders. Evaluate under 12.02.
B. Depressive syndrome. Evaluate under 12.04.
C. Anxiety disorders. Evaluate under 12.06.
D. Personality disorders. Evaluate under 12.08.

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E. Peripheral neuropathies. Evaluate under 11.14.
F. Liver damage. Evaluate under 5.05.
G. Gastritis. Evaluate under 5.04.
H. Pancreatitis. Evaluate under 5.08.
I. Seizures. Evaluate under 11.02 or 11.03.

13.00 Neoplastic Diseases, Malignant

A. Introduction: The determination of the level of impairment
resulting from malignant tumors is made from a consideration of the site
of the lesion, the histogenesis of the tumor, the extent of involvement,
the apparent adequacy and response to therapy (surgery, irradiation,
hormones, chemotherapy, etc.), and the magnitude of the post therapeutic
residuals.
B. Documentation: The diagnosis of malignant tumors should be
established on the basis of symptoms, signs, and laboratory findings.
The site of the primary, recurrent, and metastatic lesion must be
specified in all cases of malignant neoplastic diseases. If an operative
procedure has been performed, the evidence should include a copy of the
operative note and the report of the gross and microscopic examination
of the surgical specimen. If these documents are not obtainable, then
the summary of hospitalization or a report from the treating physician
must include details of the findings at surgery and the results of the
pathologist's gross and microscopic examination of the tissues.
For those cases in which a disabling impairment was not established
when therapy was begun but progression of the disease is likely, current
medical evidence should include a report of a recent examination
directed especially at local or regional recurrence, soft part or
skeletal metastases, and significant posttherapeutic residuals.
C. Evaluation. Usually, when the malignant tumor consists of a local
lesion with metastases to the regional lymph nodes which apparently has
been completely excised, imminent recurrence or metastases is not
anticipated. A number of exceptions are noted in the specific Listings.
For adjudicative purposes, ``distant metastases'' or ``metastases beyond
the regional lymph nodes'' refers to metastasis beyond the lines of the
usual radical en bloc resection.
Local or regional recurrence after radical surgery or pathological
evidence of incomplete excision by radical surgery is to be equated with
unresectable lesions (except for carcinoma of the breast, 13.09C) and,
for the purposes of our program, may be evaluated as ``inoperable.''
Local or regional recurrence after incomplete excision of a
localized and still completely resectable tumor is not to be equated
with recurrence after radical surgery. In the evaluation of lymphomas,
the tissue type and site of involvement are not necessarily indicators
of the degree of impairment.
When a malignant tumor has metastasized beyond the regional lymph
nodes, the impairment will usually be found to meet the requirements of
a specific listing. Exceptions are hormone-dependent tumors, isotope-
sensitive metastases, and metastases from seminoma of the testicles
which are controlled by definitive therapy.
When the original tumor and any metastases have apparently
disappeared and have not been evident for 3 or more years, the
impairment does not meet the criteria under this body system.
D. Effects of therapy. Significant posttherapeutic residuals, not
specifically included in the category of impairments for malignant
neoplasms, should be evaluated according to the affected body system.
Where the impairment is not listed in the Listing of Impairments and
is not medically equivalent to a listed impairment, the impact of any
residual impairment including that caused by therapy must be considered.
The therapeutic regimen and consequent adverse response to therapy may
vary widely; therefore, each case must be considered on an individual
basis. It is essential to obtain a specific description of the
therapeutic regimen, including the drugs given, dosage, frequency of
drug administration, and plans for continued drug administration. It is
necessary to obtain a description of the complications or any other
adverse response to therapy such as nausea, vomiting, diarrhea,
weakness, dermatologic disorders, or reactive mental disorders. Since
the severity of the adverse effects of anticancer chemotherapy may
change during the period of drug administration, the decision regarding
the impact of drug therapy should be based on a sufficient period of
therapy to permit proper consideration.
E. Onset. To establish onset of disability prior to the time a
malignancy is first demonstrated to be inoperable or beyond control by
other modes of therapy (and prior evidence is nonexistent) requires
medical judgment based on medically reported symptoms, the type of the
specific malignancy, its location, and extent of involvement when first
demonstrated.
13.01 Category of Impairments, Neoplastic Diseases--Malignant
13.02 Head and neck (except salivary glands--13.07, thyroid
gland--13.08, and mandible, maxilla, orbit, or temporal fossa-- 13.11):
A. Inoperable; or
B. Not controlled by prescribed therapy; or
C. Recurrent after radical surgery or irradiation; or
D. With distant metastases; or
E. Epidermoid carcinoma occurring in the pyriform sinus or posterior
third of the tongue.
13.03 Sarcoma of skin:

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A. Angiosarcoma with metastases to regional lymph nodes or beyond;
or
B. Mycosis fungoides with metastases to regional lymph nodes, or
with visceral involvement.
13.04 Sarcoma of soft parts: Not controlled by prescribed therapy.
13.05 Malignant melanoma:
A. Recurrent after wide excision; or
B. With metastases to adjacent skin (satellite lesions) or
elsewhere.
13.06 Lymph nodes:
A. Hodgkin's disease or non-Hodgkin's lymphoma with progressive
disease not controlled by prescribed therapy; or
B. Metastatic carcinoma in a lymph node (except for epidermoid
carcinoma in a lymph node in the neck) where the primary site is not
determined after adequate search; or
C. Epidermoid carcinoma in a lymph node in the neck not responding
to prescribed therapy.
13.07 Salivary glands--carcinoma or sarcoma with metastases beyond
the regional lymph nodes.
13.08 Thyroid gland--carcinoma with metastases beyond the regional
lymph nodes, not controlled by prescribed therapy.
13.09 Breast:
A. Inoperable carcinoma; or
B. Inflammatory carcinoma; or
C. Recurrent carcinoma, except local recurrence controlled by
prescribed therapy; or
D. Distant metastases from breast carcinoma (bilateral breast
carcinoma, synchronous or metachronous is usually primary in each
breast); or
E. Sarcoma with metastases anywhere.
13.10 Skeletal system (exclusive of the jaw):
A. Malignant primary tumors with evidence of metastases and not
controlled by prescribed therapy; or
B. Metastatic carcinoma to bone where the primary site is not
determined after adequate search.
13.11 Mandible, maxilla, orbit, or temporal fossa:
A. Sarcoma of any type with metastases; or
B. Carcinoma of the antrum with extension into the orbit or ethmoid
or sphenoid sinus, or with regional or distant metastases; or
C. Orbital tumors with intracranial extension; or
D. Tumors of the temporal fossa with perforation of skull and
meningeal involvement; or
E. Adamantinoma with orbital or intracranial infiltration; or
F. Tumors of Rathke's pouch with infiltration of the base of the
skull or metastases.
13.12 Brain or spinal cord:
A. Metastatic carcinoma to brain or spinal cord.
B. Evaluate other tumors under the criteria described in 11.05 and
11.08.
13.13 Lungs.
A. Unresectable or with incomplete excision; or
B. Recurrence or metastases after resection; or
C. Oat cell (small cell) carcinoma; or
D. Squamous cell carcinoma, with metastases beyond the hilar lymph
nodes; or
E. Other histologic types of carcinoma, including undifferentiated
and mixed-cell types (but excluding oat cell carcinoma, 13.13C, and
squamous cell carcinoma, 13.13D), with metastases to the hilar lymph
nodes.
13.14 Pleura or mediastinum:
A. Malignant mesothelioma of pleura; or
B. Malignant tumors, metastatic to pleura; or
C. Malignant primary tumor of the mediastinum not controlled by
prescribed therapy.
13.15 Abdomen:
A. Generalized carcinomatosis; or
B. Retroperitoneal cellular sarcoma not controlled by prescribed
therapy; or
C. Ascites with demonstrated malignant cells.
13.16 Esophagus or stomach:
A. Carcinoma or sarcoma of the esophagus; or
B. Carcinoma of the stomach with metastases to the regional lymph
nodes or extension to surrounding structure; or
C. Sarcoma of stomach not controlled by prescribed therapy; or
D. Inoperable carcinoma; or
E. Recurrence or metastases after resection.
13.17 Small intestine:
A. Carcinoma, sarcoma, or carcinoid tumor with metastases beyond the
regional lymph nodes; or
B. Recurrence of carcinoma, sarcoma, or carcinoid tumor after
resection; or
C. Sarcoma, not controlled by prescribed therapy.
13.18 Large intestine (from ileocecal valve to and including anal
canal)--carcinoma or sarcoma.
A. Unresectable; or
B. Metastases beyond the regional lymph nodes; or
C. Recurrence or metastases after resection.
13.19 Liver or gallbladder:
A. Primary or metastatic malignant tumors of the liver; or
B. Carcinoma of the gallbladder; or
C. Carcinoma of the bile ducts.
13.20 Pancreas:
A. Carcinoma except islet cell carcinoma; or
B. Islet cell carcinoma which is unresectable and physiologically
active.
13.21 Kidneys, adrenal glands, or ureters--carcinoma:
A. Unresectable; or
B. With hematogenous spread to distant sites; or

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C. With metastases to regional lymph nodes.
13.22 Urinary bladder--carcinoma. With:
A. Infiltration beyond the bladder wall; or
B. Metastases to regional lymph nodes; or
C. Unresectable; or
D. Recurrence after total cystectomy; or
E. Evaluate renal impairment after total cystectomy under the
criteria in 6.02.
13.23 Prostate gland--carcinoma not controlled by prescribed
therapy.
13.24 Testicles:
A. Choriocarcinoma; or
B. Other malignant primary tumors with progressive disease not
controlled by prescribed therapy.
13.25 Uterus--carcinoma or sarcoma (corpus or cervix).
A. Inoperable and not controlled by prescribed therapy; or
B. Recurrent after total hysterectomy; or
C. Total pelvic exenteration
13.26 Ovaries--all malignant, primary or recurrent tumors. With:
A. Ascites with demonstrated malignant cells; or
B. Unresectable infiltration; or
C. Unresectable metastases to omentum or elsewhere in the peritoneal
cavity; or
D. Distant metastases.
13.27 Leukemia: Evaluate under the criteria of 7.00ff, Hemic and
Lymphatic Sytem.
13.28 Uterine (Fallopian) tubes--carcinoma or sarcoma:
A. Unresectable, or
B. Metastases to regional lymph nodes.
13.29 Penis--carcinoma with metastases to regional lymph nodes.
13.30 Vulva--carcinoma, with distant metastases.

14.00 Immune System

A. Listed disorders include impairments involving deficiency of one
or more components of the immune system (i.e., antibody-producing B
cells; a number of different types of cells associated with cell-
mediated immunity including T-lymphocytes, macrophages and monocytes;
and components of the complement system).
B. Dysregulation of the immune system may result in the development
of a connective tissue disorder. Connective tissue disorders include
several chronic multisystem disorders that differ in their clinical
manifestation, course, and outcome. They generally evolve and persist
for months or years, may result in loss of functional abilities, and may
require long-term, repeated evaluation and management.
The documentation needed to establish the existence of a connective
tissue disorder is medical history, physical examination, selected
laboratory studies, medically acceptable imaging techniques and, in some
instances, tissue biopsy. However, the Social Security Administration
will not purchase diagnostic tests or procedures that may involve
significant risk, such as biopsies or angiograms. Generally, the
existing medical evidence will contain this information.
A longitudinal clinical record of at least 3 months demonstrating
active disease despite prescribed treatment during this period with the
expectation that the disease will remain active for 12 months is
necessary for assessment of severity and duration of impairment.
To permit appropriate application of a listing, the specific
diagnostic features that should be documented in the clinical record for
each of the disorders are summarized for systemic lupus erythematosus
(SLE), systemic vasculitis, systemic sclerosis and scleroderma,
polymyositis or dermatomyositis, and undifferentiated connective tissue
disorders.
In addition to the limitations caused by the connective tissue
disorder per se, the chronic adverse effects of treatment (e.g.,
corticosteroid-related ischemic necrosis of bone) may result in
functional loss.
These disorders may preclude performance of any gainful activity by
reason of severe loss of function in a single organ or body system, or
lesser degrees of functional loss in two or more organs/body systems
associated with significant constitutional symptoms and signs of severe
fatigue, fever, malaise, and weight loss. We use the term ``severe'' in
these listings to describe medical severity; the term does not have the
same meaning as it does when we use it in connection with a finding at
the second step of the sequential evaluation processes in
Secs. 404.1520, 416.920, and 416.924.
1. Systemic lupus erythematosus (14.02)--This disease is
characterized clinically by constitutional symptoms and signs (e.g.,
fever, fatigability, malaise, weight loss), multisystem involvement and,
frequently, anemia, leukopenia, or thrombocytopenia. Immunologically, an
array of circulating serum auto-antibodies can occur, but are highly
variable in pattern. Generally the medical evidence will show that
patients with this disease will fulfill The 1982 Revised Criteria for
the Classification of Systemic Lupus Erythematosus of the American
College of Rheumatology. (Tan, E.M., et al., Arthritis Rheum. 25: 11271-
1277, 1982).
2. Systemic vasculitis (14.03)--This disease occurs acutely in
association with adverse drug reactions, certain chronic infections and,
occasionally, malignancies. More often it is idiopathic and chronic.
There are several clinical patterns, including classical polyarteritis
nodosa, aortic arch arteritis, giant cell arteritis, Wegener's
granulomatosis, and vasculitis associated with other connective tissue
disorders (e.g., rheumatoid arthritis, SLE, Sjogren's syndrome,
cryoglobulinemia). Cutaneous vasculitis may

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or may not be associated with systemic involvement and the patterns of
vascular and ischemic involvement are highly variable. The diagnosis is
confirmed by angiography or tissue biopsy when the disease is suspected
clinically. Most patients who are stated to have this disease will have
the results of the confirmatory angiogram or biopsy in their medical
records.
3. Systemic sclerosis and scleroderma (14.04)--These disorders
constitute a spectrum of disease in which thickening of the skin is the
clinical hallmark. Raynaud's phenomena, often severe and progressive,
are especially frequent and may be the peripheral manifestation of a
generalized vasospastic abnormality in the heart, lungs, and kidneys.
The CREST syndrome (calcinosis, Raynaud's phenomena, esophageal
dysmotility, sclerodactyly, telangiectasia) is a variant that may slowly
progress to the generalized process, systemic sclerosis, over years. In
addition to skin and blood vessels, the major organ/body system
involvement includes the gastrointestinal tract, lungs, heart, kidneys,
and muscle. Although arthritis can occur, joint dysfunction results
primarily from soft tissue/cutaneous thickening, fibrosis, and
contractures.
4. Polymyositis or dermatomyositis (14.05)--This disorder is
primarily an inflammatory process in striated muscle, which can occur
alone or in association with other connective tissue disorders or
malignancy. Weakness and, less frequently, pain and tenderness of the
proximal limb-girdle musculature are the cardinal manifestations.
Involvement of the cervical muscles, the cricopharyngeals, the
intercostals, and diaphragm may occur in those with listing-level
disease. Weakness of the pelvic girdle, as contemplated in Listing
14.05A, may result in significant difficulty climbing stairs or rising
from a chair without use of the arms. Proximal limb weakness in the
upper extremities may result in inability to lift objects, and
interference with dressing and combing hair. Weakness of anterior neck
flexors may impair the ability to lift the head from the pillow in bed.
The diagnosis is supported by elevated serum muscle enzymes (creatine
phosphokinase (CPK), aminotransferases, aldolase), characteristic
abnormalities on electromyography, and myositis on muscle biopsy.
5. Undifferentiated connective tissue disorder (14.06)--This listing
includes syndromes with clinical and immunologic features of several
connective tissue disorders, but that do not satisfy the criteria for
any of the disorders described; for instance, the individual may have
clinical features of systemic lupus erythematosus and systemic
vasculitis and the serologic findings of rheumatoid arthritis. It also
includes overlap syndromes with clinical features of more than one
established connective tissue disorder. For example, the individual may
have features of both rheumatoid arthritis and scleroderma. The correct
designation of this disorder is important for assessment of prognosis.
C. Allergic disorders (e.g., asthma or atopic dermatitis) are
discussed and evaluated under the appropriate listing of the affected
body system.
D. Human immunodeficiency virus (HIV) infection.
1. HIV infection is caused by a specific retrovirus and may be
characterized by susceptibility to one or more opportunistic diseases,
cancers, or other conditions, as described in 14.08. Any individual with
HIV infection, including one with a diagnosis of acquired
immunodeficiency syndrome (AIDS), may be found disabled under this
listing if his or her impairment meets any of the criteria in 14.08 or
is of equivalent severity to any impairment in 14.08.
2. Definitions. In 14.08, the terms ``resistant to treatment,''
``recurrent,'' and ``disseminated'' have the same general meaning as
used by the medical community. The precise meaning of any of these terms
will depend upon the specific disease or condition in question, the body
system affected, the usual course of the disorder and its treatment, and
the other circumstances of the case.
``Resistant to treatment'' means that a condition did not respond
adequately to an appropriate course of treatment. Whether a response is
adequate, or a course of treatment appropriate, will depend on the facts
of the particular case.
``Recurrent'' means that a condition that responded adequately to an
appropriate course of treatment has returned after a period of remission
or regression. The extent of response (or remission) and the time
periods involved will depend on the facts of the particular case.
``Disseminated'' means that a condition is spread widely over a
considerable area or body system(s). The type and extent of the spread
will depend on the specific disease.
As used in 14.08I, ``significant involuntary weight loss'' does not
correspond to a specific minimum amount or percentage of weight loss.
Although, for purposes of this listing, an involuntary weight loss of at
least 10 percent of baseline is always considered significant, loss of
less than 10 percent may or may not be significant, depending on the
individual's baseline weight and body habitus. (For example, a 7-pound
weight loss in a 100-pound female who is 63 inches tall might be
considered significant; but a 14-pound weight loss in a 200-pound female
who is the same height might not be significant.)
3. Documentation of HIV infection. The medical evidence must include
documentation of HIV infection. Documentation may

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be by laboratory evidence or by other generally acceptable methods
consistent with the prevailing state of medical knowledge and clinical
practice.
a. Documentation of HIV infection by definitive diagnosis. A
definitive diagnosis of HIV infection is documented by one or more of
the following laboratory tests:
i. A serum specimen that contains HIV antibodies. HIV antibodies are
usually detected by a screening test. The most commonly used screening
test is the ELISA. Although this test is highly sensitive, it may yield
false positive results. Therefore, positive results from an ELISA must
be confirmed by a more definitive test (e.g., Western blot,
immunofluorescence assay).
ii. A specimen that contains HIV antigen (e.g., serum specimen,
lymphocyte culture, or cerebrospinal fluid (CSF) specimen).
iii. Other test(s) that are highly specific for detection of HIV
(e.g., polymerase chain reaction (PCR)), or that are acceptable methods
of detection consistent with the prevailing state of medical knowledge.
When laboratory testing for HIV infection has been performed, every
reasonable effort must be made to obtain reports of the results of that
testing.
Individuals who have HIV infection or other disorders of the immune
system may undergo tests to determine T-helper lymphocyte (CD4) counts.
The extent of immune depression correlates with the level or rate of
decline of the CD4 count. In general, when the CD4 count is 200/mm\3\ or
less (14 percent or less), the susceptibility to opportunistic disease
is considerably increased. However, a reduced CD4 count alone does not
establish a definitive diagnosis of HIV infection, or document the
severity or functional effects of HIV infection.
b. Other acceptable documentation of HIV infection.
HIV infection may also be documented without the definitive
laboratory evidence described in paragraph a, provided that such
documentation is consistent with the prevailing state of medical
knowledge and clinical practice and is consistent with the other
evidence. If no definitive laboratory evidence is available, HIV
infection may be documented by the medical history, clinical and
laboratory findings, and diagnosis(es) indicated in the medical
evidence. For example, a diagnosis of HIV infection will be accepted
without definitive laboratory evidence if the individual has an
opportunistic disease (e.g., toxoplasmosis of the brain, pneumocystis
carinii pneumonia (PCP)) predictive of a defect in cell-mediated
immunity, and there is no other known cause of diminished resistance to
that disease (e.g., long-term steroid treatment, lymphoma). In such
cases, every reasonable effort must be made to obtain full details of
the history, medical findings, and results of testing.
4. Documentation of the manifestations of HIV infection. The medical
evidence must also include documentation of the manifestations of HIV
infection. Documentation may be by laboratory evidence or by other
generally acceptable methods consistent with the prevailing state of
medical knowledge and clinical practice.
a. Documentation of the manifestations of HIV infection by
definitive diagnosis.
The definitive method of diagnosing opportunistic diseases or
conditions that are manifestations of HIV infection is by culture,
serological test, or microscopic examination of biopsied tissue or other
material (e.g., bronchial washings). Therefore, every reasonable effort
must be made to obtain specific laboratory evidence of an opportunistic
disease or other condition whenever this information is available. If a
histological or other test has been performed, the evidence should
include a copy of the appropriate report. If the report is not
obtainable, the summary of hospitalization or a report from the treating
source should include details of the findings and results of the
diagnostic studies (including radiographic studies) or microscopic
examination of the appropriate tissues or body fluids.
Although a reduced CD4 lymphocyte count may show that there is an
increased susceptibility to opportunistic infections and diseases (see
14.00D3a, above), that alone does not establish the presence, severity,
or functional effects of a manifestation of HIV infection.
b. Other acceptable documentation of the manifestations of HIV
infection.
Manifestations of HIV infection may also be documented without the
definitive laboratory evidence described in paragraph a, provided that
such documentation is consistent with the prevailing state of medical
knowledge and clinical practice and is consistent with the other
evidence. If no definitive laboratory evidence is available,
manifestations of HIV infection may be documented by medical history,
clinical and laboratory findings, and diagnosis(es) indicated in the
medical evidence. In such cases, every reasonable effort must be made to
obtain full details of the history, medical findings, and results of
testing.
Documentation of cytomegalovirus (CMV) disease (14.08D) presents
special problems because diagnosis requires identification of viral
inclusion bodies or a positive culture from the affected organ, and the
absence of any other infectious agent. A positive serology test
identifies infection with the virus, but does not confirm a disease
process. With the exception of chorioretinitis (which may be diagnosed
by an ophthalmologist), documentation of CMV disease requires
confirmation by biopsy or other generally acceptable methods consistent
with the prevailing state of medical knowledge and clinical practice.

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5. Manifestations specific to women. Most women with severe
immunosuppression secondary to HIV infection exhibit the typical
opportunistic infections and other conditions, such as pneumocystis
carinii pneumonia (PCP), candida esophagitis, wasting syndrome,
cryptococcosis, and toxoplasmosis. However, HIV infection may have
different manifestations in women than in men. Adjudicators must
carefully scrutinize the medical evidence and be alert to the variety of
medical conditions specific to or common in women with HIV infection
that may affect their ability to function in the workplace.
Many of these manifestations (e.g. vulvovaginal candidiasis, pelvic
inflammatory disease) occur in women with or without HIV infection, but
can be more severe or resistant to treatment, or occur more frequently
in a woman whose immune system is suppressed. Therefore, when evaluating
the claim of a woman with HIV infection, it is important to consider
gynecologic and other problems specific to women, including any
associated symptoms (e.g., pelvic pain), in assessing the severity of
the impairment and resulting functional limitations. Manifestations of
HIV infection in women may be evaluated under the specific criteria
(e.g., cervical cancer under 14.08E), under an applicable general
category (e.g., pelvic inflammatory disease under 14.08A5) or, in
appropriate cases, under 14.08N.
6. Evaluation. The criteria in 14.08 do not describe the full
spectrum of diseases or conditions manifested by individuals with HIV
infection. As in any case, consideration must be given to whether an
individual's impairment(s) meets or equals in severity any other listing
in appendix 1 of subpart P (e.g., a neoplastic disorder listed in
13.00ff). Although 14.08 includes cross-references to other listings for
the more common manifestations of HIV infection, other listings may
apply.
In addition, the impact of all impairments, whether or not related
to HIV infection, must be considered. For example, individuals with HIV
infection may manifest signs and symptoms of a mental impairment (e.g.,
anxiety, depression), or of another physical impairment. Medical
evidence should include documentation of all physical and mental
impairments, and the impairment(s) should be evaluated not only under
the relevant listing(s) in 14.08, but under any other appropriate
listing(s).
It is also important to remember that individuals with HIV
infection, like all other individuals, are evaluated under the full
five-step sequential evaluation process described in Sec. 404.1520 and
Sec. 416.920. If an individual with HIV infection is working and
engaging in substantial gainful activity (SGA), or does not have a
severe impairment, the case will be decided at the first or second step
of the sequential evaluation process, and does not require evaluation
under these listings. For an individual with HIV infection who is not
engaging in SGA and has a severe impairment, but whose impairment(s)
does not meet or equal in severity the criteria of a listing, evaluation
must proceed through the final steps of the sequential evaluation
process (or, as appropriate, the steps in the medical improvement review
standard) before any conclusion can be reached on the issue of
disability.
7. Effect of treatment. Medical treatment must be considered in
terms of its effectiveness in ameliorating the signs, symptoms, and
laboratory abnormalities of the specific disorder, or of the HIV
infection itself (e.g., antiretroviral agents) and in terms of any side
effects of treatment that may further impair the individual.
Response to treatment and adverse or beneficial consequences of
treatment may vary widely. For example, an individual with HIV infection
who develops pneumonia or tuberculosis may respond to the same
antibiotic regimen used in treating individuals without HIV infection,
but another individual with HIV infection may not respond to the same
regimen. Therefore, each case must be considered on an individual basis,
along with the effects of treatment on the individual's ability to
function.
A specific description of the drugs or treatment given (including
surgery), dosage, frequency of administration, and a description of the
complications or response to treatment should be obtained. The effects
of treatment may be temporary or long term. As such, the decision
regarding the impact of treatment should be based on a sufficient period
of treatment to permit proper consideration.
8. Functional criteria. Paragraph N of 14.08 establishes standards
for evaluating manifestations of HIV infection that do not meet the
requirements listed in 14.08A-M. Paragraph N is applicable for
manifestations that are not listed in 14.08A-M, as well as those listed
in 14.08A-M that do not meet the criteria of any of the rules in 14.08A-
M.
For individuals with HIV infection evaluated under 14.08N, listing-
level severity will be assessed in terms of the functional limitations
imposed by the impairment. The full impact of signs, symptoms, and
laboratory findings on the claimant's ability to function must be
considered. Important factors to be considered in evaluating the
functioning of individuals with HIV infection include, but are not
limited to: symptoms, such as fatigue and pain; characteristics of the
illness, such as the frequency and duration of manifestations or periods
of exacerbation and remission in the disease course; and the functional
impact of treatment for the disease, including the side effects of
medication.

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As used in 14.08N, ``repeated'' means that the conditions occur on
an average of 3 times a year, or once every 4 months, each lasting 2
weeks or more; or the conditions do not last for 2 weeks but occur
substantially more frequently than 3 times in a year or once every 4
months; or they occur less often than an average of 3 times a year or
once every 4 months but last substantially longer than 2 weeks.
To meet the criteria in 14.08N, an individual with HIV infection
must demonstrate a marked level of restriction in one of three general
areas of functioning: activities of daily living; social functioning;
and difficulties in completing tasks due to deficiencies in
concentration, persistence, or pace. Functional restrictions may result
from the impact of the disease process itself on mental or physical
functioning, or both. This could result from extended or intermittent
symptoms, such as depression, fatigue, or pain, resulting in a
limitation of the ability to concentrate, to persevere at a task, or to
perform the task at an acceptable rate of speed. Limitations may also
result from the side effects of medication.
When ``marked'' is used as a standard for measuring the degree of
functional limitation, it means more than moderate, but less than
extreme. A marked limitation does not represent a quantitative measure
of the individual's ability to do an activity for a certain percentage
of the time. A marked limitation may be present when several activities
or functions are impaired or even when only one is impaired. However, an
individual need not be totally precluded from performing an activity to
have a marked limitation, as long as the degree of limitation is such as
to seriously interfere with the ability to function independently,
appropriately, and effectively. The term ``marked'' does not imply that
the impaired individual is confined to bed, hospitalized, or in a
nursing home.
Activities of daily living include, but are not limited to, such
activities as doing household chores, grooming and hygiene, using a post
office, taking public transportation, and paying bills. An individual
with HIV infection who, because of symptoms such as pain imposed by the
illness or its treatment, is not able to maintain a household or take
public transportation on a sustained basis or without assistance (even
though he or she is able to perform some self-care activities) would
have marked limitation of activities of daily living.
Social functioning includes the capacity to interact appropriately
and communicate effectively with others. An individual with HIV
infection who, because of symptoms or a pattern of exacerbation and
remission caused by the illness or its treatment, cannot engage in
social interaction on a sustained basis (even though he or she is able
to communicate with close friends or relatives) would have marked
difficulty maintaining social functioning.
Completing tasks in a timely manner involves the ability to sustain
concentration, persistence, or pace to permit timely completion of tasks
commonly found in work settings. An individual with HIV infection who,
because of HIV-related fatigue or other symptoms, is unable to sustain
concentration or pace adequate to complete simple work-related tasks
(even though he or she is able to do routine activities of daily living)
would have marked difficulty completing tasks.

14.01 Category of Impairments, Immune System

14.02 Systemic lupus erythematosus. Documented as described in
14.00B1, with:
A. One of the following:
1. Joint involvement, as described under the criteria in 1.00; or
2. Muscle involvement, as described under the criteria in 14.05; or
3. Ocular involvement, as described under the criteria in 2.00ff; or
4. Respiratory involvement, as described under the criteria in
3.00ff; or
5. Cardiovascular involvement, as described under the criteria in
4.00ff or 14.04D; or
6. Digestive involvement, as described under the criteria in 5.00ff;
or
7. Renal involvement, as described under the criteria in 6.00ff; or
8. Skin involvement, as described under the criteria in 8.00ff; or
9. Neurological involvement, as described under the criteria in
11.00ff; or
10. Mental involvement, as described under the criteria in 12.00ff.

B. Lesser involvement of two or more organs/body systems listed in
paragraph A, with significant, documented, constitutional symptoms and
signs of severe fatigue, fever, malaise, and weight loss. At least one
of the organs/body systems must be involved to at least a moderate level
of severity.
14.03 Systemic vasculitis. Documented as described in 14.00B2,
including documentation by angiography or tissue biopsy, with:
A. Involvement of a single organ or body system, as described under
the criteria in 14.02A.

B. Lesser involvement of two or more organs/body systems listed in
14.02A, with significant, documented, constitutional symptoms and signs
of severe fatigue, fever, malaise, and weight loss. At least one of the
organs/body systems must be involved to at least a moderate level of
severity.
14.04 Systemic sclerosis and scleroderma. Documented as described
in 14.00B3, with:
A. One of the following:

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1. Muscle involvement, as described under the criteria in 14.05; or
2. Respiratory involvement, as described under the criteria in
3.00ff; or
3. Cardiovascular involvement, as described under the criteria in
4.00ff; or
4. Digestive involvement, as described under the criteria in 5.00ff;
or
5. Renal involvement, as described under the criteria in 6.00ff.

C. Generalized scleroderma with digital contractures.

D. Severe Raynaud's phenomena, characterized by digital ulcerations,
ischemia, or gangrene.
14.05 Polymyositis or dermatomyositis. Documented as described in
14.00B4, with:
A. Severe proximal limb-girdle (shoulder and/or pelvic) muscle
weakness, as described in 14.00B4.

B. Less severe limb-girdle muscle weakness than in 14.05A,
associated with cervical muscle weakness and one of the following to at
least a moderate level of severity:
1. Impaired swallowing with dysphagia and episodes of aspiration due
to cricopharyngeal weakness, or
2. Impaired respiration due to intercostal and diaphragmatic muscle
weakness.

C. If associated with malignant tumor, as described under the
criteria in 13.00ff.

D. If associated with generalized connective tissue disease,
described under the criteria in 14.02, 14.03, 14.04, or 14.06.
14.06 Undifferentiated connective tissue disorder. Documented as
described in 14.00B5, and with impairment as described under the
criteria in 14.02A, 14.02B, or 14.04.
14.07 Immunoglobulin deficiency syndromes or deficiencies of cell-
mediated immunity, excepting HIV infection. Associated with documented,
recurrent severe infection occurring 3 or more times within a 5-month
period.
14.08 Human immunodeficiency virus (HIV) infection. With
documentation as described in 14.00D3 and one of the following:
A. Bacterial infections:
1. Mycobacterial infection (e.g., caused by M. avium-intracellulare,
M. kansasii, or M. tuberculosis) at a site other than the lungs, skin,
or cervical or hilar lymph nodes; or pulmonary tuberculosis resistant to
treatment; or
2. Nocardiosis; or
3. Salmonella bacteremia, recurrent non-typhoid; or
4. Syphilis or neurosyphilis--evaluate sequelae under the criteria
for the affected body system (e.g., 2.00 Special Senses and Speech, 4.00
Cardiovascular System, 11.00 Neurological); or
5. Multiple or recurrent bacterial infection(s), including pelvic
inflammatory disease, requiring hospitalization or intravenous
antibiotic treatment 3 or more times in 1 year.

B. Fungal infections:
1. Aspergillosis; or
2. Candidiasis, at a site other than the skin, urinary tract,
intestinal tract, or oral or vulvovaginal mucous membranes; or
candidiasis involving the esophagus, trachea, bronchi, or lungs; or
3. Coccidioidomycosis, at a site other than the lungs or lymph
nodes; or
4. Cryptococcosis, at a site other than the lungs (e.g.,
cryptococcal meningitis); or
5. Histoplasmosis, at a site other than the lungs or lymph nodes; or
6. Mucormycosis.

C. Protozoan or helminthic infections:
1. Cryptosporidiosis, isosporiasis, or microsporidiosis, with
diarrhea lasting for 1 month or longer; or
2. Pneumocystis carinii pneumonia or extrapulmonary pneumocystis
carinii infection; or
3. Strongyloidiasis, extra-intestinal; or
4. Toxoplasmosis of an organ other than the liver, spleen, or lymph
nodes.

D. Viral infections:
1. Cytomegalovirus disease (documented as described in 14.00D4b) at
a site other than the liver, spleen, or lymph nodes; or
2. Herpes simplex virus causing:
a. Mucocutaneous infection (e.g., oral, genital, perianal) lasting
for 1 month or longer; or
b. Infection at a site other than the skin or mucous membranes
(e.g., bronchitis, pneumonitis, esophagitis, or encephalitis); or
c. Disseminated infection; or
3. Herpes zoster, either disseminated or with multidermatomal
eruptions that are resistant to treatment; or
4. Progressive multifocal leukoencephalopathy; or
5. Hepatitis, as described under the criteria in 5.05.

E. Malignant neoplasms:
1. Carcinoma of the cervix, invasive, FIGO stage II and beyond; or

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2. Kaposi's sarcoma with:
a. Extensive oral lesions; or
b. Involvement of the gastrointestinal tract, lungs, or other
visceral organs; or
c. Involvement of the skin or mucous membranes, as described under
the criteria in 14.08F; or
3. Lymphoma (e.g., primary lymphoma of the brain, Burkitt's
lymphoma, immunoblastic sarcoma, other non-Hodgkins lymphoma, Hodgkin's
disease); or
4. Squamous cell carcinoma of the anus.

F. Conditions of the skin or mucous membranes (other than described
in B2, D2, or D3, above) with extensive fungating or ulcerating lesions
not responding to treatment (e.g., dermatological conditions such as
eczema or psoriasis, vulvovaginal or other mucosal candida, condyloma
caused by human papillomavirus, genital ulcerative disease), or evaluate
under the criteria in 8.00ff.

G. Hematologic abnormalities:
1. Anemia, as described under the criteria in 7.02; or
2. Granulocytopenia, as described under the criteria in 7.15; or
3. Thrombocytopenia, as described under the criteria in 7.06.

H. Neurological abnormalities:
1. HIV encephalopathy, characterized by cognitive or motor
dysfunction that limits function and progresses; or
2. Other neurological manifestations of HIV infection (e.g.,
peripheral neuropathy) as described under the criteria in 11.00ff.

I. HIV wasting syndrome, characterized by involuntary weight loss of
10 percent or more of baseline (or other significant involuntary weight
loss, as described in 14.00D2) and, in the absence of a concurrent
illness that could explain the findings, either:
1. Chronic diarrhea with two or more loose stools daily lasting for
1 month or longer; or
2. Chronic weakness and documented fever greater than 38 deg. C
(100.4 deg. F) for the majority of 1 month or longer.

J. Diarrhea, lasting for 1 month or longer, resistant to treatment,
and requiring intravenous hydration, intravenous alimentation, or tube
feeding.

K. Cardiomyopathy, as described under the criteria in 4.00ff or
11.04.

L. Nephropathy, as described under the criteria in 6.00ff.

M. One or more of the following infections (other than described in
A-L, above), resistant to treatment or requiring hospitalization or
intravenous treatment 3 or more times in 1 year (or evaluate sequelae
under the criteria for the affected body system).
1. Sepsis; or
2. Meningitis; or
3. Pneumonia; or
4. Septic arthritis; or
5. Endocarditis; or
6. Radiographically documented sinusitis.

N. Repeated (as defined in 14.00D8) manifestations of HIV infection
(including those listed in 14.08A-M, but without the requisite findings,
e.g., carcinoma of the cervix not meeting the criteria in 14.08E,
diarrhea not meeting the criteria in 14.08J, or other manifestations,
e.g., oral hairy leukoplakia, myositis) resulting in significant,
documented symptoms or signs (e.g., fatigue, fever, malaise, weight
loss, pain, night sweats) and one of the following at the marked level
(as defined in 14.00D8):
1. Restriction of activities of daily living; or
2. Difficulties in maintaining social functioning; or
3. Difficulties in completing tasks in a timely manner due to
deficiencies in concentration, persistence, or pace.

Part B

Medical criteria for the evaluation of impairments of children under
age 18 (where criteria in Part A do not give appropriate consideration
to the particular disease process in childhood).
Sec.
100.00 Growth Impairment.
101.00 Musculoskeletal System.
102.00 Special Senses and Speech.
103.00 Respiratory System.
104.00 Cardiovascular System.
105.00 Digestive System.
106.00 Genito-Urinary System.
107.00 Hemic and Lymphatic System.
108.00 [Reserved]
109.00 Endocrine System.
110.00 Multiple Body Systems.
111.00 Neurological.
112.00 Mental and Emotional Disorders.
113.00 Neoplastic Diseases, Malignant.
114.00 Immune System.

100.00 Growth Impairment

A. Impairment of growth may be disabling in itself or it may be an
indicator of the severity of the impairment due to a specific disease
process.
Determinations of growth impairment should be based upon the
comparison of current height with at least three previous
determinations, including length at birth, if available. Heights (or
lengths) should be plotted

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on a standard growth chart, such as derived from the National Center for
Health Statistics: NCHS Growth Charts. Height should be measured without
shoes. Body weight corresponding to the ages represented by the heights
should be furnished. The adult heights of the child's natural parents
and the heights and ages of siblings should also be furnished. This will
provide a basis upon which to identify those children whose short
stature represents a familial characteristic rather than a result of
disease. This is particularly true for adjudication under 100.02B.
B. Bone age determinations should include a full descriptive report
of roentgenograms specifically obtained to determine bone age and must
cite the standardization method used. Where roentgenograms must be
obtained currently as a basis for adjudication under 100.03, views of
the left hand and wrist should be ordered. In addition, roentgenograms
of the knee and ankle should be obtained when cessation of growth is
being evaluated in an older child at, or past, puberty.
C. The criteria in this section are applicable until closure of the
major epiphyses. The cessation of significant increase in height at that
point would prevent the application of these criteria.
100.01 Category of Impairments, Growth
100.02 Growth impairment, considered to be related to an additional
specific medically determinable impairment, and one of the following:
A. Fall of greater than 15 percentiles in height which is sustained;
or
B. Fall to, or persistence of, height below the third percentile.
100.03 Growth impairment, not identified as being related to an
additional, specific medically determinable impairment. With:
A. Fall of greater than 25 percentiles in height which is sustained;
and
B. Bone age greater than two standard deviations (2 SD) below the
mean for chronological age (see 100.00B).

101.00 Musculoskeletal System

A. Rheumatoid arthritis. Documentation of the diagnosis of juvenile
rheumatoid arthritis should be made according to an established
protocol, such as that published by the Arthritis Foundation, Bulletin
on the Rheumatic Diseases. Vol. 23, 1972-1973 Series, p 712.
Inflammatory signs include persistent pain, tenderness, erythema,
swelling, and increased local temperature of a joint.
B. The measurements of joint motion are based on the technique for
measurements described in the ``Joint Method of Measuring and
Recording.'' published by the American Academy of Orthopedic Surgeons in
1965, or ``The Extremities and Back'' in Guides to the Evaluation of
Permanent Impairment, Chicago, American Medical Association, 1971,
Chapter 1, pp. 1-48.
C. Degenerative arthritis may be the end stage of many skeletal
diseases and conditions, such as traumatic arthritis, collagen disorders
septic arthritis, congenital dislocation of the hip, aseptic necrosis of
the hip, slipped capital femoral epiphyses, skeletal dysplasias, etc.
101.01 Category of Impairments, Musculoskeletal
101.02 Juvenile rheumatoid arthritis. With:
A. Persistence or recurrence of joint inflammation despite three
months of medical treatment and one of the following:
1. Limitation of motion of two major joints of 50 percent or
greater; or
2. Fixed deformity of two major weight-bearing joints of 30 degrees
or more; or
3. Radiographic changes of joint narrowing, erosion, or subluxation;
or
4. Persistent or recurrent systemic involvement such as
iridocyclitis or pericarditis; or
B. Steroid dependence.
101.03 Deficit of musculoskeletal function due to deformity or
musculoskeletal disease and one of the following:
A. Walking is markedly reduced in speed or distance despite orthotic
or prosthetic devices; or
B. Ambulation is possible only with obligatory bilateral upper limb
assistance (e.g., with walker, crutches); or
C. Inability to perform age-related personal self-care activities
involving feeding, dressing, and personal hygiene.
101.05 Disorders of the spine.
A. Fracture of vertebra with cord involvement (substantiated by
appropriate sensory and motor loss); or
B. Scoliosis (congenital idiopathic or neuromyopathic). With:
1. Major spinal curve measuring 60 degrees or greater; or
2. Spinal fusion of six or more levels. Consider under a disability
for one year from the time of surgery; thereafter evaluate the residual
impairment; or
3. FEV (vital capacity) of 50 percent or less of predicted normal
values for the individual's measured (actual) height; or
C. Kyphosis or lordosis measuring 90 degrees or greater.
101.08 Chronic osteomyelitis with persistence or recurrence of
inflammatory signs or drainage for at least 6 months despite prescribed
therapy and consistent radiographic findings.

102.00 Special Senses and Speech

A. Visual impairments in children. Impairment of central visual
acuity should be determined with use of the standard Snellen test chart.
Where this cannot be used, as in very young children, a complete
description should be provided of the findings using other appropriate
methods of examination, including a description of the techniques

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used for determining the central visual acuity for distance.
The accommodative reflex is generally not present in children under
6 months of age. In premature infants, it may not be present until 6
months plus the number of months the child is premature. Therefore
absence of accommodative reflex will be considered as indicating a
visual impairment only in children above this age (6 months).
Documentation of a visual disorder must include description of the
ocular pathology.
B. Hearing impairments in children. The criteria for hearing
impairments in children take into account that a lesser impairment in
hearing which occurs at an early age may result in a severe speech and
language disorder.
Improvement by a hearing aid, as predicted by the testing procedure,
must be demonstrated to be feasible in that child, since younger
children may be unable to use a hearing aid effectively.
The type of audiometric testing performed must be described and a
copy of the results must be included. The pure tone air conduction
hearing levels in 102.08 are based on American National Standard
Institute Specifications for Audiometers, S3.6-1969 (ANSI-1969). The
report should indicate the specifications used to calibrate the
audiometer.
The finding of a severe impairment will be based on the average
hearing levels at 500, 1000, 2000, and 3000 Hertz (Hz) in the better
ear, and on speech discrimination, as specified in Sec. 102.08.
102.01 Category of Impairments, Special Sense Organs
102.02 Impairments of central visual acuity.
A. Remaining vision in the better eye after best correction is 20/
200 or less; or
B. For children below 3 years of age at time of adjudication:
1. Absence of accommodative reflex (see 102.00A for exclusion of
children under 6 months of age); or
2. Retrolental fibroplasia with macular scarring or
neovascularization; or
3. Bilateral congenital cataracts with visualization of retinal red
reflex only or when associated with other ocular pathology.
102.08 Hearing impairments.
A. For children below 5 years of age at time of adjudication,
inability to hear air conduction thresholds at an average of 40 decibels
(db) hearing level or greater in the better ear; or
B. For children 5 years of age and above at time of adjudication:
1. Inability to hear air conduction thresholds at an average of 70
decibels (db) or greater in the better ear; or
2. Speech discrimination scores at 40 percent or less in the better
ear; or
3. Inability to hear air conduction thresholds at an average of 40
decibels (db) or greater in the better ear, and a speech and language
disorder which significantly affects the clarity and content of the
speech and is attributable to the hearing impairment.

103.00 Respiratory System

A. Introduction. The listings in this section describe impairments
resulting from respiratory disorder based on symptoms, physical signs,
laboratory test abnormalities, and response to a regimen of treatment
prescribed by a treating source. Respiratory disorders, along with any
associated impairment(s) must be established by medical evidence.
Evidence must be provided in sufficient detail to permit an independent
reviewer to evaluate the severity of the impairment. Reasonable efforts
should be made to ensure evaluation by a program physician specializing
in childhood respiratory impairments or a qualified pediatrician.
Many children, especially those who have listing-level impairments,
will have received the benefit of medically prescribed treatment.
Whenever there is such evidence, the longitudinal clinical record must
include a description of the treatment prescribed by the treating source
and response, in addition to information about the nature and severity
of the impairment. It is important to document any prescribed treatment
and response because this medical management may have improved the
child's functional status. The longitudinal record should provide
information regarding functional recovery, if any.
Some children will not have received ongoing treatment or have an
ongoing relationship with the medical community, despite the existence
of a severe impairment(s). A child who does not receive treatment may or
may not be able to show an impairment that meets the criteria of these
listings. Even if a child does not show that his or her impairment meets
the criteria of these listings, the child may have an impairment(s)
equivalent in severity to one of the listed impairments or be disabled
because of a substantial reduction in the ability to function
independently, appropriately, and effectively in an age-appropriate
manner. Unless the claim can be decided favorably on the basis of the
current evidence, a longitudinal record is still important because it
will provide information about such things as the ongoing medical
severity of the impairment, the level of the child's functioning, and
the frequency, severity, and duration of symptoms. Also, the asthma
listing specifically includes a requirement for continuing signs and
symptoms despite a regimen of prescribed treatment.
Evaluation should include consideration of adverse effects of
respiratory impairment in all relevant body systems, and especially on
the child's growth and development or mental functioning, as described
under the growth impairment (100.00), neurological (111.00), and mental
disorders (112.00) listings.

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It must be remembered that these listings are only examples of
common respiratory disorders that are severe enough to prevent a child
from functioning independently, appropriately, and effectively in an
age-appropriate manner. When a child has a medically determinable
impairment that is not listed, an impairment which does not meet a
listing, or a combination of impairments no one of which meets a
listing, we may make an equivalence determination on medical or
functional grounds. Also, with respect to children claiming SSI benefits
under title XVI of the Act who have an impairment(s) with a level of
severity which does not meet or equal (medically or functionally) the
criteria of the listings, we will determine whether the impairment(s) is
of comparable severity to one that would disable an adult. In these
cases, we will perform an individualized functional assessment to
determine whether the child is disabled.
B. Documentation of Pulmonary Function Testing. The results of
spirometry that are used for adjudication, under the 103.02 A and B,
103.03, and 103.04 of these listings should be expressed in liters (L),
body temperature and pressure saturated with water vapor (BTPS). The
reported one-second forced expiratory volume (FEV1) and forced
vital capacity (FVC) should represent the largest of at least three
satisfactory forced expiratory maneuvers. Two of the satisfactory
spirograms should be reproducible for both pre-bronchodilator tests and,
if indicated, post-bronchodilator tests. A value is considered
reproducible if it does not differ from the largest value by more than 5
percent or 0.1 L, whichever is greater. The highest values of the
FEV1 and FVC, whether from the same or different tracings, should
be used to assess the severity of the respiratory impairment. Peak flow
should be achieved early in expiration, and the spirogram should have a
smooth contour with gradually decreasing flow throughout expiration. The
zero time for measurement of the FEV1 and FVC, if not distinct,
should be derived by linear back-extrapolation of peak flow to zero
volume. A spirogram is satisfactory for measurement of the FEV1 if
the expiratory volume at the back-extrapolated zero time is less than 5
percent of the FVC or 0.1 L, whichever is greater. The spirogram is
satisfactory for measurement of the FVC if maximal expiratory effort
continues for at least 6 seconds, or if there is a plateau in the
volume-time curve with no detectable change in expired volume (VE)
during the last 2 seconds of maximal expiratory effort.
Spirometry should be repeated after administration of an aerosolized
bronchodilator under supervision of the testing personnel if the pre-
bronchodilator FEV1 value is less than the appropriate reference
value in table I or III, as appropriate. If a bronchodilator is not
administered, the reason should be clearly stated in the report.
Pulmonary function studies should not be performed unless the clinical
status is stable (e.g., the child is not having an asthmatic attack or
suffering from an acute respiratory infection or other chronic illness).
Wheezing is common in asthma, chronic bronchitis, or chronic obstructive
pulmonary disease and does not preclude testing. Pulmonary function
studies performed to assess airflow obstruction without testing after
bronchodilators cannot be used to assess levels of impairment in the
range that prevents a child from performing age-appropriate activities,
unless the use of bronchodilators is contraindicated. Post-
bronchodilator testing should be performed 10 minutes after
bronchodilator administration. The dose and name of the bronchodilator
administered should be specified. The values in 103.02 and 103.04 must
only be used as criteria for the level of ventilatory impairment that
exists during the child's most stable state of health (i.e., any period
in time except during or shortly after an exacerbation).
The appropriately labeled spirometric tracing, showing the child's
name, date of testing, distance per second on the abscissa and distance
per liter (L) on the ordinate, must be incorporated into the file. The
manufacturer and model number of the device used to measure and record
the spirogram should be stated. The testing device must accurately
measure both time and volume, the latter to within 1 percent of a 3 L
calibrating volume. If the spirogram was generated by any means other
than direct pen linkage to a mechanical displacement-type spirometer,
the spirometric tracing must show a recorded calibration of volume units
using a mechanical volume input such as a 3 L syringe.
If the spirometer directly measures flow, and volume is derived by
electronic integration, the linearity of the device must be documented
by recording volume calibrations at three different flow rates of
approximately 30 L/min (3 L/6 sec), 60 L/min (3 L/3 sec), and 180 L/min
(3 L/sec). The volume calibrations should agree to within 1 percent of a
3 L calibrating volume. The proximity of the flow sensor to the child
should be noted, and it should be stated whether or not a BTPS
correction factor was used for the calibration recordings and for the
child's actual spirograms.
The spirogram must be recorded at a speed of at least 20 mm/sec and
the recording device must provide a volume excursion of at least 10 mm/
L. If reproductions of the original spirometric tracings are submitted,
they must be legible and have a time scale of at least 20 mm/sec and a
volume scale of at least 10 mm/L to permit independent measurements.
Calculation of FEV1 from a flow volume tracing is not acceptable,
i.e., the

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spirogram and calibrations must be presented in a volume-time format at
a speed of at least 20 mm/sec and a volume excursion of at least 10 mm/L
to permit independent evaluation.
A statement should be made in the pulmonary function test report of
the child's ability to understand directions, as well as his or her
efforts and cooperation in performing the pulmonary function tests.
Purchase of a pulmonary function test is appropriate only when the
child is capable of performing reproducible forced expiratory maneuvers.
This capability usually occurs around age 6. Purchase of a pulmonary
function test may be appropriate when there is a question of whether an
impairment meets or is equivalent in severity to a listing, and the
claim cannot otherwise be favorably decided.
The pulmonary function tables in 103.02 and 103.04 are based on
measurement of standing height without shoes. If a child has marked
spinal deformities (e.g., kyphoscoliosis), the measured span between the
fingertips with the upper extremities abducted 90 degrees should be
substituted for height when this measurement is greater than the
standing height without shoes.
C. Documentation of chronic impairment of gas exchange.
1. Arterial blood gas studies (ABGS). An ABGS performed at rest
(while breathing room air, awake and sitting or standing) should be
analyzed in a laboratory certified by a State or Federal agency. If the
laboratory is not certified, it must submit evidence of participation in
a national proficiency testing program as well as acceptable quality
control at the time of testing. The report should include the altitude
of the facility and the barometric pressure on the date of analysis.
Purchase of resting ABGS may be appropriate when there is a question
of whether an impairment meets or is equivalent in severity to a
listing, and the claim cannot otherwise be favorably decided. Before
purchasing resting ABGS, a program physician, preferably one experienced
in the care of children with pulmonary disease, must review the clinical
and laboratory data short of this procedure, including spirometry, to
determine whether obtaining the test would present a significant risk to
the child.
2. Oximetry. Pulse oximetry may be substituted for arterial blood
gases in children under 12 years of age. The oximetry unit should employ
the basic technology of spectrophotometric plethysmography as described
in Taylor, M.B., and Whitwain, J.G., ``Current Status of Pulse
Oximetry,'' ``Anesthesia,'' Vol. 41, No. 9, pp. 943-949, 1986. The unit
should provide a visual display of the pulse signal and the
corresponding oxygen saturation. A hard copy of the readings (heart rate
and saturation) should be provided. Readings should be obtained for a
minimum of 5 minutes. The written report should describe patient
activity during the recording, i.e., sleep rate, feeding, or exercise.
Correlation between the actual heart rate determined by a trained
observer and that displayed by the oximeter should be provided. A
statement should be made in the report of the child's effort and
cooperation during the test.
Purchase of oximetry may be appropriate when there is a question of
whether an impairment meets or is equivalent in severity to a listing,
and the claim cannot otherwise be favorably decided.
D. Cystic fibrosis is a disorder that affects either the respiratory
or digestive body systems or both and may impact on a child's growth and
development. It is responsible for a wide and variable spectrum of
clinical manifestations and complications. Confirmation of the diagnosis
is based upon an elevated sweat sodium concentration or chloride
concentration accompanied by one or more of the following: the presence
of chronic obstructive pulmonary disease, insufficiency of exocrine
pancreatic function, meconium ileus, or a positive family history. The
quantitative pilocarpine iontophoresis procedure for collection of sweat
content must be utilized. Two methods are acceptable: the ``Procedure
for the Quantitative Iontophoretic Sweat Test for Cystic Fibrosis,''
published by the Cystic Fibrosis Foundation and contained in, ``A Test
for Concentration of Electrolytes in Sweat in Cystic Fibrosis of the
Pancreas Utilizing Pilocarpine Iontophoresis,'' Gibson, I.E., and Cooke,
R.E., ``Pediatrics,'' Vol 23: 545, 1959; or the ``Wescor Macroduct
System.'' To establish the diagnosis of cystic fibrosis, the sweat
sodium or chloride content must be analyzed quantitatively using an
acceptable laboratory technique. Another diagnostic test is the ``CF
gene mutation analysis'' for homozygosity of the cystic fibrosis gene.
The pulmonary manifestations of this disorder should be evaluated under
103.04. The nonpulmonary aspects of cystic fibrosis should be evaluated
under the listings for the digestive system (105.00) or growth
impairments (100.00). Because cystic fibrosis may involve the
respiratory and digestive body systems, as well as impact on a child's
growth and development, the combined effects of this involvement must be
considered in case adjudication.
E. Bronchopulmonary dysplasia (BPD). Bronchopulmonary dysplasia is a
form of chronic obstructive pulmonary disease that arises as a
consequence of acute lung injury in the newborn period and treatment of
hyaline membrane disease, meconium aspiration, neonatal pneumonia and
apnea of prematurity. The diagnosis is established by the requirement
for continuous or nocturnal supplemental oxygen for more than 30 days,

[[Page 435]]

in association with characteristic radiographic changes and clinical
signs of respiratory dysfunction, including retractions, rales,
wheezing, and tachypnea.
103.01 Category of Impairments, Respiratory System
103.02 Chronic pulmonary insufficiency. With:
A. Chronic obstructive pulmonary disease, due to any cause, with the
FEV1 equal to or less than the value specified in Table I
corresponding to the child's height without shoes. (In cases of marked
spinal deformity, see 103.00B.);

Table I
------------------------------------------------------------------------
FEV1 equal
Height without shoes to or less
Height without shoes (centimeters) (inches) than (L,
BTPS)
------------------------------------------------------------------------
119 or less......................... 46 or less............ 0.65
120-129............................. 47-50................. 0.75
130-139............................. 51-54................. 0.95
140-149............................. 55-58................. 1.15
150-159............................. 59-62................. 1.35
160-164............................. 63-64................. 1.45
165-169............................. 65-66................. 1.55
170 or more......................... 67 or more............ 1.65
------------------------------------------------------------------------

B. Chronic restrictive ventilatory disease, due to any cause, with
the FVC equal to or less than the value specified in table II
corresponding to the child's height without shoes. (In cases of marked
spinal deformity, see 103.00B.);

Table II
------------------------------------------------------------------------
FVC equal
Height without shoes to or less
Height without shoes (centimeters) (inches) than (L,
BTPS)
------------------------------------------------------------------------
119 or less......................... 46 or less............ 0.65
120-129............................. 47-50................. 0.85
130-139............................. 51-54................. 1.05
140-149............................. 55-58................. 1.25
150-159............................. 59-62................. 1.45
160-164............................. 63-64................. 1.65
165-169............................. 65-66................. 1.75
170 or more......................... 67 or more............ 2.05
------------------------------------------------------------------------

C Frequent need for:
1. Mechanical ventilation; or
2. Nocturnal supplemental oxygen as required by persistent or
recurrent episodes of hypoxemia;

D. The presence of a tracheostomy in a child under 3 years of age;

E. Bronchopulmonary dysplasia characterized by two of the following:
1. Prolonged expirations; or
2. Intermittent wheezing or increased respiratory effort as
evidenced by retractions, flaring and tachypnea; or
3. Hyperinflation and scarring on a chest radiograph or other
appropriate imaging techniques; or
4. Bronchodilator or diuretic dependency; or
5. A frequent requirement for nocturnal supplemental oxygen; or
6. Weight disturbance with:
a. An involuntary weight loss (or failure to gain weight at an
appropriate rate for age) resulting in a fall of 15 percentiles from
established growth curve (on standard growth charts) which persists for
2 months or longer; or
b. An involuntary weight loss (or failure to gain weight at an
appropriate rate for age) resulting in a fall to below the third
percentile from established growth curve (on standard growth charts)
which persists for 2 months or longer;

F. Two required hospital admissions (each longer than 24 hours)
within a 6-month period for recurrent lower respiratory tract infections
or acute respiratory distress associated with:
1. Chronic wheezing or chronic respiratory distress; or
2. Weight disturbance with:
a. An involuntary weight loss (or failure to gain weight at an
appropriate rate for age) resulting in a fall of 15 percentiles from
established growth curve (on standard growth charts) which persists for
2 months or longer; or
b. An involuntary weight loss (or failure to gain weight at an
appropriate rate for age) resulting in a fall to below the third
percentile from established growth curve (on standard growth charts)
which persists for 2 months or longer;

G. Chronic hypoventilation (PaCO2 greater than 45 mm Hg) or
chronic cor pulmonale as described under the appropriate criteria in
104.02;

H. Growth impairment as described under the criteria in 100.00.
103.03 Asthma. With:
A. FEV1 equal to or less than the value specified in Table I of
103.02A;

[[Page 436]]

least 12 consecutive months must be used to determine the frequency of
attacks;

C. Persistent low-grade wheezing between acute attacks or absence of
extended symptom-free periods requiring daytime and nocturnal use of
sympathomimetic bronchodilators with one of the following:
1. Persistent prolonged expiration with radiographic or other
appropriate imaging techniques evidence of pulmonary hyperinflation or
peribronchial disease; or
2. Short courses of corticosteroids that average more than 5 days
per month for at least 3 months during a 12-month period;

D. Growth impairment as described under the criteria in 100.00.
103.04 Cystic fibrosis. With:
A. An FEV1 equal to or less than the appropriate value
specified in Table III corresponding to the child's height without
shoes. (In cases of marked spinal deformity, see 103.00B.);

B. For children in whom pulmonary function testing cannot be
performed, the presence of two of the following:
1. History of dyspnea on exertion or accumulation of secretions as
manifested by repetitive coughing or cyanosis; or
2. Persistent bilateral rales and rhonchi or substantial reduction
of breath sounds related to mucous plugging of the trachea or bronchi;
or
3. Radiographic evidence of extensive disease, such as thickening of
the proximal bronchial airways or persistence of bilateral peribronchial
infiltrates;

D. Episodes of bronchitis or pneumonia or hemoptysis (more than
blood-streaked sputum) or respiratory failure (documented according to
3.00C), requiring physician intervention, occurring at least once every
2 months or at least six times a year. Each inpatient hospitalization
for longer than 24 hours for treatment counts as two episodes, and an
evaluation period of at least 12 consecutive months must be used to
determine the frequency of episodes;

E. Growth impairment as described under the criteria in 100.00.

Table III
[Applicable only for evaluation under 103.04A--cystic fibrosis]
------------------------------------------------------------------------
FEV 1
equal to
Height without shoes (centimeters) Height without shoes or less
(inches) than (L,
BTPS)
------------------------------------------------------------------------
119 or less......................... 46 or less............. 0.75
120-129............................. 47-50.................. 0.85
130-139............................. 51-54.................. 1.05
140-149............................. 55-58.................. 1.35
150-159............................. 59-62.................. 1.55
160-164............................. 63-64.................. 1.85
165-169............................. 65-66.................. 2.05
170 or more......................... 67 or more............. 2.25
------------------------------------------------------------------------

104.00 Cardiovascular System

A. Introduction

The listings in this section describe childhood impairments
resulting from congenital or acquired cardiovascular disease based on
symptoms, physical signs, laboratory test abnormalities, and response to
a regimen of therapy prescribed by a treating source. A longitudinal
clinical record covering a period of not less than 3 months of
observations and therapy is usually necessary for the assessment of
severity and expected duration unless the child is a neonate or the
claim can be decided favorably on the basis of the current evidence. All
relevant evidence must be considered in assessing a child's disability.
Reasonable efforts should be made to ensure evaluation by a program
physician specializing in childhood cardiovascular impairments or a
qualified pediatrician.
Examples of congenital defects include: abnormalities of cardiac
septation, such as ventricular septal defect or atrioventricular (AV)
canal; abnormalities resulting in cyanotic heart disease, such as
tetralogy of Fallot or transposition of the vessels; valvular defects or
obstructions to ventricular outflow, including pulmonary or aortic
stenosis and/or coarctation of the aorta; and major abnormalities of
ventricular development, including hypoplastic left heart syndrome or
pulmonary tricuspid atresia with hypoplastic right ventricle. Acquired
heart disease may be due to cardiomyopathy, rheumatic heart disease,
Kawasaki syndrome, or other etiologies. Recurrent arrhythmias, severe
enough to cause functional impairment, may be seen with congenital or
acquired heart disease or, more rarely, in children with structurally
normal hearts.
Cardiovascular impairments, especially chronic heart failure and
congenital heart disease, may result in impairments in other body
systems including, but not limited to, growth, neurological, and mental.
Therefore, evaluation should include consideration of

[[Page 437]]

the adverse effects of cardiovascular impairment in all relevant body
systems, and especially on the child's growth and development, or mental
functioning, as described under the Growth impairment (100.00),
Neurological (111.00), and Mental retardation (112.05) listings.
Many children, especially those who have listing-level impairments,
will have received the benefit of medically prescribed treatment.
Whenever there is evidence of such treatment, the longitudinal clinical
record must include a description of the therapy prescribed by the
treating source and response, in addition to information about the
nature and severity of the impairment. It is important to document any
prescribed therapy and response because this medical management may have
improved the child's functional status. The longitudinal record should
provide information regarding functional recovery, if any.
Some children will not have received ongoing treatment or have an
ongoing relationship with the medical community despite the existence of
a severe impairment(s). Unless the claim can be decided favorably on the
basis of the current evidence, a longitudinal record is still important
because it will provide information about such things as the ongoing
medical severity of the impairment, the level of the child's
functioning, and the frequency, severity, and duration of symptoms.
Also, several listings include a requirement for continuing signs and
symptoms despite a regimen of prescribed treatment. Even though a child
who does not receive treatment may not be able to show an impairment
that meets the criteria of these listings, the child may have an
impairment(s) equivalent in severity to one of the listed impairments or
be disabled because of a substantial reduction in the ability to
function independently, appropriately, and effectively in an age-
appropriate manner.
Indeed, it must be remembered that these listings are only examples
of common cardiovascular disorders that are severe enough to prevent a
child from functioning independently, appropriately, and effectively in
an age-appropriate manner. When a child has a medically determinable
impairment that is not listed, or a combination of impairments no one of
which meets a listing, we will make an equivalence determination. Also,
with respect to children claiming SSI benefits under title XVI of the
Act who have an impairment(s) with a level of severity which does not
meet or equal the criteria of the cardiovascular listings, we will
determine whether the impairment(s) is of comparable severity to one
that would disable an adult. In these cases, an individualized
functional assessment is crucial to the evaluation of a child's ability
to function independently, appropriately, and effectively in an age-
appropriate manner when the impairment(s) is severe but the criteria of
these listings are not met or equaled.

B. Documentation

Each child's file must include sufficiently detailed reports on
history, physical examinations, laboratory studies, and any prescribed
therapy and response to allow an independent reviewer to assess the
severity and duration of the cardiovascular impairment. Data should be
obtained preferably from an office or center experienced in pediatric
cardiac assessment. The actual electrocardiographic tracing (or
adequately marked photocopy) and echocardiogram report with a copy of
relevant echocardiographic views should be included (see part A,
4.00C1).
Results of additional studies necessary to substantiate the
diagnosis or to document the severity of the impairment, including two-
dimensional and Doppler echocardiography, and radionuclide
ventriculograms, should be obtained as appropriate according to part A,
4.00C3. Ambulatory electrocardiographic monitoring may also be obtained
if necessary to document the presence or severity of an arrhythmia.
Exercise testing, though increasingly used, is still less frequently
indicated in children than in adults, and can rarely be successfully
performed in children under 6 years of age. It may be of value in the
assessment of some arrhythmias, in the assessment of the severity of
chronic heart failure, and in the assessment of recovery of function
following cardiac surgery or other therapy. It will only be purchased by
the Social Security Administration if the case cannot be decided based
on the available evidence and, if purchased, must be performed in a
specialty center for pediatric cardiology or other facility qualified to
perform exercise testing for children.
Purchased exercise tests should be performed using a generally
accepted protocol consistent with the prevailing state of medical
knowledge and clinical practice. An exercise test should not be
purchased for a child for whom the performance of the test is considered
to constitute a significant risk by a program physician. See 4.00C2c.
Cardiac catheterization will not be purchased by the Social Security
Administration. If the results of catheterization are otherwise
available, they should be obtained.

C. Treatment and Relationship to Functional Status

In general, conclusions about the severity of a cardiovascular
impairment cannot be made on the basis of type of treatment rendered or
anticipated. The overall clinical and laboratory evidence, including the
treatment plan(s) or results, should be persuasive that a listing-level
impairment exists. The

[[Page 438]]

amount of function restored and the time required for improvement after
treatment (medical, surgical, or a prescribed program of progressive
physical activity) vary with the nature and extent of the disorder, the
type of treatment, and other factors. Depending upon the timing of this
treatment in relation to the alleged onset date of disability,
impairment evaluation may need to be deferred for a period of up to 3
months from the date of treatment to permit consideration of treatment
effects.
Evaluation should not be deferred if the claim can be favorably
decided based upon the available evidence.
The most life-threatening forms of congenital heart disease and
cardiac impairments, such as those listed in 104.00D, almost always
require surgical treatment within the first year of life to prevent
early death. Even with surgery, these impairments are so severe that it
is likely that the impairment will continue to be disabling long enough
to meet the duration requirement because of significant residual
impairment post-surgery, or the recovery time from surgery, or a
combination of both factors. Therefore, when the impairment is one of
those named in 104.00D, or is as severe as one of those impairments, the
presence of a listing-level impairment can usually be found on the basis
of planned or actual cardiac surgery.
A child who has undergone surgical treatment for life-threatening
heart disease will be found under a disability for 12 months following
the date of surgery under 104.06H (for infants with life-threatening
cardiac disease) or 104.09 (for a child of any age who undergoes cardiac
transplantation) because of the uncertainty during that period
concerning outcome or long-term results. After 12 months, continuing
disability evaluation will be based upon residual impairment, which will
consider the clinical course following treatment and comparison of
symptoms, signs, and laboratory findings preoperatively and after the
specified period. (See Secs. 416.994a, 404.1594, or 416.994, as
appropriate, for our rules on medical improvement and whether an
individual is no longer disabled.)

D. Congenital Heart Disease

Some congenital defects usually lead to listing-level impairment in
the first year of life and require surgery within the first year as a
life-saving measure. Examples of impairments that in most instances will
require life-saving surgery before age 1, include, but are not limited
to, the following: hypoplastic left heart syndrome; critical aortic
stenosis with neonatal heart failure; critical coarctation of the aorta,
with or without associated anomalies; complete AV canal defects;
transposition of the great arteries; tetralogy of Fallot; and pulmonary
atresia with intact ventricular septum.
In addition, there are rarer defects which may lead to early
mortality and that may require multiple surgical interventions or a
combination of surgery and other major interventional procedures (e.g.,
multiple ``balloon'' catheter procedures). Examples of such defects
include single ventricle, tricuspid atresia, and multiple ventricular
septal defects.
Pulmonary vascular obstructive disease can cause cardiac impairment
in young children. When a large or nonrestrictive septal defect or
ductus is present, pulmonary artery mean pressures of at least 70
percent of mean systemic levels are used as a criterion of listing-level
impairment. In the absence of such a defect (i.e., with primary
pulmonary hypertension, or in some connective tissue disorders with
cardiopulmonary involvement and pulmonary vascular destruction),
listing-level impairment may be present at lower levels of pulmonary
artery pressure, in the range of at least 50 percent of mean systemic
levels.

E. Chronic Heart Failure

Chronic heart failure in infants and children may manifest itself by
pulmonary or systemic venous congestion, including cardiomegaly, chronic
dyspnea, tachypnea, orthopnea, or hepatomegaly; or symptoms of limited
cardiac output, such as weakness or fatigue; or a need for cardiotonic
drugs. Fatigue or exercise intolerance in an infant may be manifested by
prolonged feeding time associated with signs of cardiac impairment,
including excessive respiratory effort and sweating. Other
manifestations of chronic heart failure during infancy may include
failure to gain weight or involuntary loss of weight and repeated lower
respiratory tract infections.
Cardiomegaly or ventricular dysfunction must be present and
demonstrated by imaging techniques, such as two-dimensional and Doppler
echocardiography. (Reference: Feigenbaum, Harvey, ``Echocardiography,''
4th Edition, Lea and Febiger, 1986, Appendix, pp. 621-639.) Chest x-ray
(6 ft. PA film) will be considered indicative of cardiomegaly if the
cardiothoracic ratio is over 60 percent at age 1 year or less, or 55
percent at more than 1 year of age.
Findings of cardiomegaly on chest x-ray must be accompanied by other
evidence of chronic heart failure or ventricular dysfunction. This
evidence may include clinical evidence, such as hepatomegaly, edema, or
pulmonary venous congestion; or echocardiographic evidence, such as
marked ventricular dilatation above established normals for age, or
markedly reduced ejection fraction or shortening fraction.

[[Page 439]]

F. Valvular Heart Disease

Valvular heart disease requires documentation by appropriate imaging
techniques, including Doppler echocardiogram studies or cardiac
catheterization if catheterization results are available from a treating
source or other source of record. Listing-level impairment is usually
associated with critical aortic stenosis in a newborn child, persistent
heart failure, arrhythmias, or valve replacement and ongoing
anticoagulant therapy. The usual time after valvular surgery for
adequate assessment of the results of treatment is considered to be 3
months.

G. Rheumatic Heart Disease

The diagnosis should be made in accordance with the current revised
Jones criteria for guidance in the diagnosis of rheumatic fever.
104.01 Category of Impairments, Cardiovascular System
104.02 Chronic heart failure. Documented by clinical and laboratory
findings as described in 104.00E, and with one of the following:
A. Persistent tachycardia at rest (see Table I);
OR
B. Persistent tachypnea at rest (see Table II), or markedly
decreased exercise tolerance (see 104.00E);
OR
C. Recurrent arrhythmias, as described in 104.05;
OR
D. Growth disturbance, with:
1. An involuntary weight loss (or failure to gain weight at an
appropriate rate for age) resulting in a fall of 15 percentiles from
established growth curve (on standard growth charts) which persists for
2 months or longer; or
2. An involuntary weight loss (or failure to gain weight at an
appropriate rate for age) resulting in a fall to below the third
percentile from established growth curve (on standard growth charts)
which persists for 2 months or longer; or
3. Growth impairment as described under the criteria in 100.00.

Table I--Tachycardia at Rest
------------------------------------------------------------------------
Apical
heart
Age (beats
per
minute)
------------------------------------------------------------------------
Under 1 yr................................................... 150
1 through 3 yrs.............................................. 130
4 through 9 yrs.............................................. 120
10 through 15 yrs............................................ 110
Over 15 yrs.................................................. 100
------------------------------------------------------------------------

Table II--Tachypnea at Rest
------------------------------------------------------------------------
Respiratory
rate over
Age (per
minute)
------------------------------------------------------------------------
Under 1 yr................................................. 40
1 through 5 yrs............................................ 35
6 through 9 yrs............................................ 30
Over 9 yrs................................................. 25
------------------------------------------------------------------------

104.03 Hypertensive cardiovascular disease. With persistently
elevated blood pressure equal to or greater than the 95th percentile for
age (see Table III), and one of the following:
A. Impaired renal function, as described in 106.02;
OR
B. Cerebrovascular damage, as described in 111.06;
OR
C. Chronic heart failure as described in 104.02.

Table III--Elevated Blood Pressure
------------------------------------------------------------------------
Systolic over Diastolic over
Age (mmHg) OR (mmHg)
------------------------------------------------------------------------
Under 1 month...................... 95 --
1 month through 2 yrs.............. 112 74
3 through 5 yrs.................... 116 76
6 through 9 yrs.................... 122 78
10 through 12 yrs.................. 126 82
13 through 15 yrs.................. 136 86
16 to 18 yrs....................... 142 92
------------------------------------------------------------------------

104.05 Recurrent arrhythmias, such as persistent or recurrent heart
block (A-V dissociation), repeated symptomatic tachyarrhythmias or
bradyarrhythmias or long QT syndrome arrhythmias, not related to
reversible causes such as electrolyte abnormalities or digitalis
glycoside or antiarrhythmic drug toxicity, resulting in uncontrolled
repeated episodes of cardiac syncope or near syncope and arrhythmia
despite prescribed treatment, including electronic pacemaker (see
104.00A if there is no

[[Page 440]]

prescribed treatment), and documented by resting or ambulatory (Holter)
electrocardiography coincident with the occurrence of syncope or near
syncope.
104.06 Congenital heart disease. With one of the following:
A. Cyanotic heart disease, with persistent, chronic hypoxemia as
manifested by:
1. Hematocrit of 55 percent or greater on two or more evaluations
within a 3-month period; or
2. Arterial O2 saturation of less than 90 percent in room air,
or resting PO2 of 60 Torr or less; or
3. Hypercyanotic spells, syncope, characteristic squatting, or other
incapacitating symptoms directly related to documented cyanotic heart
disease; or
4. Exercise intolerance with increased hypoxemia on exertion;
OR
B. Chronic heart failure with evidence of ventricular dysfunction,
as described in 104.02;
OR
C. Recurrent arrhythmias as described in 104.05;
OR
D. Secondary pulmonary vascular obstructive disease with a mean
pulmonary arterial pressure elevated to at least 70 percent of the mean
systemic arterial pressure;
OR
E. Congenital valvular or other stenotic defects, or valvular
regurgitation, as described in 104.00F and 104.07;
OR
F. Symptomatic acyanotic heart disease, with ventricular dysfunction
resulting in significant restriction of age-appropriate activities or
inability to complete age-appropriate tasks (see 104.00A);
OR
G. Growth failure, as described in 100.00;
OR
H. For infants under 12 months of age at the time of filing, with
life-threatening congenital heart impairment that will or has required
surgical treatment in the first year of life, consider the infant to be
under a disability until the attainment of age 1 or for 12 months after
surgery, whichever is the later event; thereafter, evaluate impairment
severity with reference to 104.02 to 104.08.
104.07 Valvular heart disease or other stenotic defects, or
valvular regurgitation, documented by appropriate imaging techniques or
cardiac catheterization.
A. Evaluate according to criteria in 104.02, 104.05, 111.06, or
11.04;
OR
B. Critical aortic stenosis in newborn.
104.08 Cardiomyopathies, documented by appropriate imaging
techniques, including echocardiography or cardiac catheterization, if
catheterization results are available from a treating source. Impairment
must be associated with an ejection fraction of 50 percent or less and
significant left ventricular dilatation using standardized age-
appropriate echocardiographic ventricular cavity measurements. Evaluate
under the criteria in 104.02, 104.05, or 111.06.
104.09 Cardiac transplantation. Consider under a disability for 1
year following surgery; thereafter, evaluate residual impairment under
104.02 to 104.08.
104.13 Chronic rheumatic fever or rheumatic heart disease. Consider
under a disability for 18 months from the established onset of
impairment with one of the following:
A. Persistence of rheumatic fever activity for 6 months or more
which is manifested by significant murmur(s), cardiac enlargement (see
104.00E) or ventricular dysfunction, and other abnormal laboratory
findings, as for example, an elevated sedimentation rate or ECG
findings;
OR
B. Evidence of chronic heart failure, as described under 104.02;
OR
C. Recurrent arrhythmias, as described under 104.05.
104.14 Hyperlipidemia. Documented Type II homozygous hyperlipidemia
with repeated plasma cholesterol levels of 500 mg/ml or greater, with
one of the following:
A. Myocardial ischemia, as described in 4.04B or 4.04C;
OR
B. Significant aortic stenosis documented by Doppler
echocardiographic techniques or cardiac catheterization;
OR
C. Major disruption of normal life activities by repeated
hospitalizations for plasmapheresis or other prescribed therapies,
including liver transplant;
OR
D. Recurrent pancreatitis complicating hyperlipidemia.
104.15 Kawasaki syndrome. With one of the following:
A. Major coronary artery aneurysm;
OR
B. Chronic heart failure, as described in 104.02.

105.00 Digestive System

A. Disorders of the digestive system which result in disability
usually do so because of interference with nutrition and growth,
multiple recurrent inflammatory lesions, or other complications of the
disease. Such lesions or complications usually respond to treatment. To
constitute a listed impairment, these must be shown to have persisted or
be expected to persist despite prescribed therapy for a continuous
period of at least 12 months.
B. Documentation of gastrointestinal impairments should include
pertinent operative findings, radiographic studies, endoscopy,

[[Page 441]]

and biopsy reports. Where a liver biopsy has been performed in chronic
liver disease, documentation should include the report of the biopsy.
C. Growth retardation and malnutrition. When the primary disorder of
the digestive tract has been documented, evaluate resultant malnutrition
under the criteria described in 105.08. Evaluate resultant growth
impairment under the criteria described in 100.03. Intestinal disorders,
including surgical diversions and potentially correctable congenital
lesions, do not represent a severe impairment if the individual is able
to maintain adequate nutrition growth and development.
D. Multiple congenital anomalies. See related criteria, and consider
as a combination of impairments.
105.01 Category of Impairments, Digestive.
105.03 Esophageal obstruction, caused by atresia, stricture, or
stenosis with malnutrition as described under the criteria in 105.08.
105.05 Chronic liver disease. With one of the following:
A. Inoperable billiary atresia demonstrated by X-ray or surgery; or
B. Intractable ascites not attributable to other causes, with serum
albumin of 3.0 gm./100 ml. or less; or
C. Esophageal varices (demonstrated by angiography, barium swallow,
or endoscopy or by prior performance of a specific shunt or plication
procedure); or
D. Hepatic coma, documentated by findings from hospital records; or
E. Hepatic encephalopathy. Evaluate under the criteria in 112.02; or
F. Chronic active inflammation or necrosis documented by SGOT
persistently more than 100 units or serum bilirubin of 2.5 mg. percent
or greater.
105.07 Chronic inflammatory bowel disease (such as ulcerative
colitis, regional enteritis), as documented in 105.00. With one of the
following:
A. Intestinal manifestations or complications, such as obstruction,
abscess, or fistula formation which has lasted or is expected to last 12
months; or
B. Malnutrition as described under the criteria in 105.08; or
C. Growth impairment as described under the criteria in 100.03.
105.08 Malnutrition, due to demonstrable gastrointestinal disease
causing either a fall of 15 percentiles of weight which persists or the
persistence of weight which is less than the third percentile (on
standard growth charts). And one of the following:
A. Stool fat excretion per 24 hours:
1. More than 15 percent in infants less than 6 months.
2. More than 10 percent in infants 6-18 months.
3. More than 6 percent in children more than 18 months; or
B. Persistent hematocrit of 30 percent or less despite prescribed
therapy; or
C. Serum carotene of 40 mcg./100 ml. or less; or
D. Serum albumin of 3.0 gm./100 ml. or less.

106.00 Genito-Urinary System

A. Determination of the presence of chronic renal disease will be
based upon the following factors:
1. History, physical examination, and laboratory evidence of renal
disease.
2. Indications of its progressive nature or laboratory evidence of
deterioration of renal function.
B. Renal transplant. The amount of function restored and the time
required to effect improvement depend upon various factors including
adequacy of post transplant renal function, incidence of renal
infection, occurrence of rejection crisis, presence of systemic
complications (anemia, neuropathy, etc.) and side effects of
corticosteroid or immuno-suppressive agents. A period of at least 12
months is required for the individual to reach a point of stable medical
improvement.
C. Evaluate associated disorders and complications according to the
appropriate body system listing.
106.01 Category of Impairments, Genito-Urinary.
106.02 Chronic renal disease. With:
A. Persistent elevation of serum creatinine to 3 mg. per deciliter
(100 ml.) or greater over at least 3 months; or
B. Reduction of creatinine clearance to 30 ml. per minute (43
liters/24 hours) per 1.73 m^{2 of body surface area over at least 3
months; or
C. Chronic renal dialysis program for irreversible renal failure; or
D. Renal transplant. Consider under a disability for 12 months
following surgery; thereafter, evaluate the residual impairment (see
106.00B).
106.06 Nephrotic syndrome, with edema not controlled by prescribed
therapy. And:
A. Serum albumin less than 2 gm./100 ml.; or
B. Proteinuria more than 2.5 gm./1.73m^{2/ day.

107.00 Hemic and Lymphatic System

A. Sickle cell disease. Refers to a chronic hemolytic anemia
associated with sickle cell hemoglobin, either homozygous or in
combination with thalassemia or with another abnormal hemoglobin (such
as C or F).
Appropriate hematologic evidence for sickle cell disease, such as
hemoglobin electrophoresis must be included. Vaso-occlusive, hemolytic,
or aplastic episodes

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should be documented by description of severity, frequency, and
duration.
Disability due to sickle cell disease may be solely the result of a
severe, persistent anemia or may be due to the combination of chronic
progressive or episodic manifestations in the presence of a less severe
anemia.
Major visceral episodes causing disability include meningitis,
osteomyelitis, pulmonary infections or infarctions, cerebrovascular
accidents, congestive heart failure, genitourinary involvement, etc.
B. Coagulation defects. Chronic inherited coagulation disorders must
be documented by appropriate laboratory evidence such as abnormal
thromboplastin generation, coagulation time, or factor assay.
C. Acute leukemia. Initial diagnosis of acute leukemia must be based
upon definitive bone marrow pathologic evidence. Recurrent disease may
be documented by peripheral blood, bone marrow, or cerebrospinal fluid
examination. The pathology report must be included.
The designated duration of disability implicit in the finding of a
listed impairment is contained in 107.11. Following the designated time
period, a documented diagnosis itself is no longer sufficient to
establish a severe impairment. The severity of any remaining impairment
must be evaluated on the basis of the medical evidence.
107.01 Category of Impairments, Hemic and Lymphatic.
107.03 Hemolytic anemia (due to any cause). Manifested by
persistence of hematocrit of 26 percent or less despite prescribed
therapy, and reticulocyte count of 4 percent or greater.
107.05 Sickle cell disease. With:
A. Recent, recurrent, severe vaso-occlusive crises (musculoskeletal,
vertebral, abdominal); or
B. A major visceral complication in the 12 months prior to
application; or
C. A hyperhemolytic or aplastic crisis within 12 months prior to
application; or
D. Chronic, severe anemia with persistence of hematocrit of 26
percent or less; or
E. Congestive heart failure, cerebrovascular damage, or emotional
disorder as described under the criteria in 104.02, 111.00ff, or
112.00ff.
107.06 Chronic idiopathic thrombocytopenic purpura of childhood
with purpura and thrombocytopenia of 40,000 platelets/cu. mm. or less
despite prescribed therapy or recurrent upon withdrawal of treatment.
107.08 Inherited coagulation disorder. With:
A. Repeated spontaneous or inappropriate bleeding; or
B. Hemarthrosis with joint deformity.
107.11 Acute leukemia. Consider under a disability:
A. For 2\1/2\ years from the time of initial diagnosis; or
B. For 2\1/2\ years from the time of recurrence of active disease.

108.00 [Reserved]

109.00 Endocrine System

A. Cause of disability. Disability is caused by a disturbance in the
regulation of the secretion or metabolism of one or more hormones which
are not adequately controlled by therapy. Such disturbances or
abnormalities usually respond to treatment. To constitute a listed
impairment these must be shown to have persisted or be expected to
persist despite prescribed therapy for a continuous period of at least
12 months.
B. Growth. Normal growth is usually a sensitive indicator of health
as well as of adequate therapy in children. Impairment of growth may be
disabling in itself or may be an indicator of a severe disorder
involving the endocrine system or other body systems. 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 under the appropriate sections.
C. Documentation. Description of characteristic history, physical
findings, and diagnostic laboratory data must be included. Results of
laboratory tests will be considered abnormal if outside the normal range
or greater than two standard deviations from the mean of the testing
laboratory. Reports in the file should contain the information provided
by the testing laboratory as to their normal values for that test.
D. Hyperfunction of the adrenal cortex. Evidence of growth
retardation must be documented as described in 100.00. Elevated blood or
urinary free cortisol levels are not acceptable in lieu of urinary 17-
hydroxycorticosteroid excretion for the diagnosis of adrenal cortical
hyperfunction.
E. Adrenal cortical insufficiency. Documentation must include
persistent low plasma cortisol or low urinary 17-hydroxycorticosteroids
or 17-ketogenic steroids and evidence of unresponsiveness to ACTH
stimulation.
109.01 Category of Impairments, Endrocrine
109.02 Thyroid Disorders.
A. Hyperthyroidism (as documented in 109.00C). With clinical
manifestations despite prescribed therapy, and one of the following:
1. Elevated serum thyroxine (T4) and either elevated free
T4 or resin T3 uptake; or
2. Elevated thyroid uptake of radioiodine; or
3. Elevated serum triiodothyronine (T3).
B. Hypothyroidism. With one of the following, despite prescribed
therapy:
1. IQ of 70 or less; or
2. Growth impairment as described under the criteria in 100.02 A and
B; or
3. Precocious puberty.

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109.03 Hyperparathyroidism (as documented in 109.00C). With:
A. Repeated elevated total or ionized serum calcium; or
B. Elevated serum parathyroid hormone.
109.04 Hypoparathyroidism or Pseudohypoparathyroidism. With:
A. Severe recurrent tetany or convulsions which are unresponsive to
prescribed therapy; or
B. Growth retardation as described under criteria in 100.02 A and B.
109.05 Diabetes insipidus, documented by pathologic hypertonic
saline or water deprivation test. And one of the following:
A. Intracranial space-occupying lesion, before or after surgery; or
B. Unresponsiveness to Pitressin; or
C. Growth retardation as described under the criteria in 100.02 A
and B; or
D. Unresponsive hypothalmic thirst center, with chronic or recurrent
hypernatremia; or
E. Decreased visual fields attributable to a pituitary lesion.
109.06 Hyperfunction of the adrenal cortex (Primary or secondary).
With:
A. Elevated urinary 17-hyroxycortico-steroids (or 17-ketogenic
steroids) as documented in 109.00 C and D; and
B. Unresponsiveness to low-dose dexamethasone suppression.
109.07 Adrenal cortical insufficiency (as documented in 109.00 C
and E) with recent, recurrent episodes of circulatory collapse.
109.08 Juvenile diabetes mellitus (as documented in 109.00C)
requiring parenteral insulin. And one of the following, despite
prescribed therapy:
A. Recent, recurrent hospitalizations with acidosis; or
B. Recent, recurrent episodes of hypoglycemia; or
C. Growth retardation as described under the criteria in 100.02 A or
B; or
D. Impaired renal function as described under the criteria in
106.00ff.
109.09 Iatrogenic hypercorticoid state.
With chronic glucocorticoid therapy resulting in one of the
following:
A. Osteoporosis; or
B. Growth retardation as described under the criteria in 100.02 A or
B; or
C. Diabetes mellitus as described under the criteria in 109.08; or
D. Myopathy as described under the criteria in 111.06; or
E. Emotional disorder as described under the criteria in 112.00ff.
109.10 Pituitary dwarfism (with documented growth hormone
deficiency). And growth impairment as described under the criteria in
100.02B.
109.11 Adrenogenital syndrome. With:
A. Recent, recurrent self-losing episodes despite prescribed
therapy; or
B. Inadequate replacement therapy manifested by accelerated bone age
and virilization, or
C. Growth impairment as described under the criteria in 100.02 A or
B.
109.12 Hypoglycemia (as documented in 109.00C). With recent,
recurrent hypoglycemic episodes producing convulsion or coma.
109.13 Gonadal Dysgenesis (Turner's Syndrome), chromosomally
proven. Evaluate the resulting impairment under the criteria for the
appropriate body system.

110.00 Multiple Body Systems

A. This section refers to those life-threatening catastrophic
congenital abnormalities and other serious hereditary, congenital, or
acquired disorders that usually affect two or more body systems and are
expected to:
1. Result in early death or developmental attainment of less than 2
years of age as described in listing 110.08 (e.g., anencephaly or Tay-
Sachs); or
2. Produce long-term, if not life-long, significant interference
with age-appropriate major daily or personal care activities as
described in listings 110.06 and 110.07. (Significant interference with
age-appropriate activities is considered to exist where the
developmental milestone age did not exceed two-thirds of the
chronological age at the time of evaluation and such interference has
lasted or could be expected to last at least 12 months.) See 112.00C for
a discussion of developmental milestone criteria and evaluation of age-
appropriate activities.
Down syndrome (except for mosaic Down syndrome, which is to be
evaluated under listing 110.07) established by clinical findings,
including the characteristic physical features, and laboratory evidence
is considered to meet the requirement of listing 110.06 commencing at
birth. Examples of disorders that should be evaluated under listing
110.07 include mosaic Down syndrome and chromosomal abnormalities other
than Down syndrome, in which a pattern of multiple impairments
(including mental retardation) is known to occur, phenylketonuria (PKU),
fetal alcohol syndrome, and severe chronic neonatal infections such as
toxoplasmosis, rubella syndrome, cytomegalic inclusion disease, and
herpes encephalitis.
B. Documentation must include confirmation of a positive diagnosis
by a clinical description of the usual abnormal physical findings
associated with the condition and definitive laboratory tests, including
chromosomal analysis, where appropriate (e.g., Down syndrome). Medical
evidence that is persuasive that a positive diagnosis has been confirmed
by appropriate laboratory testing, at some time prior to evaluation, is
acceptable in lieu of a copy of the actual laboratory report.

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C. When multiple body system manifestations do not meet one of the
established criteria of one of the listings, the combined impairments
must be evaluated together to determine if they are equal in severity to
a listed impairment.
110.01 Category of Impairments, Multiple Body Systems
110.06 Down syndrome (excluding mosaic Down syndrome) established
by clinical and laboratory findings, as described in 110.00B. Consider
the child disabled from birth.
110.07 Multiple body dysfunction due to any confirmed (see 110.00B)
hereditary, congenital, or acquired condition with one of the following:
A. Persistent motor dysfunction as a result of hypotonia and/or
musculoskeletal weakness, postural reaction deficit, abnormal primitive
reflexes, or other neurological impairment as described in 111.00C, and
with significant interference with age-appropriate major daily or
personal care activities, which in an infant or young child include such
activities as head control, swallowing, following, reaching, grasping,
turning, sitting, crawling, walking, taking solids, feeding self; or
B. Mental impairment as described under the criteria in 112.05 or
112.12; or
C. Growth impairment as described under the criteria in 100.02A or
B; or
D. Significant interference with communication due to speech,
hearing, or visual impairments as described under the criteria in 102.00
and 111.09; or
E. Cardiovascular impairments as described under the criteria in
104.00; or
F. Other impairments such as, but not limited to, malnutrition,
hypothyroidism, or seizures should be evaluated under the criteria in
105.08, 109.02 or 111.02 and 111.03, or the criteria for the affected
body system.
110.08 Catastrophic congenital abnormalities or disease. With:
A. A positive diagnosis (such as anencephaly, trisomy D or E,
cyclopia, etc.), generally regarded as being incompatible with
extrauterine life; or
B. A positive diagnosis (such as cri du chat, Tay-Sachs Disease)
wherein attainment of the growth and development level of 2 years is not
expected to occur.

111.00 Neurological

A. Seizure disorder must be substantiated by at least one detailed
description of a typical seizure. Report of recent documentation should
include an electroencephalogram and neurological examination. Sleep EEG
is preferable, especially with temporal lobe seizures. Frequency of
attacks and any associated phenomena should also be substantiated.
Young children may have convulsions in association with febrile
illnesses. Proper use of 111.02 and 111.03 requires that a seizure
disorder be established. Although this does not exclude consideration of
seizures occurring during febrile illnesses, it does require
documentation of seizures during nonfebrile periods.
There is an expected delay in control of seizures when treatment is
started, particularly when changes in the treatment regimen are
necessary. Therefore, a seizure disorder should not be considered to
meet the requirements of 111.02 or 111.03 unless it is shown that
seizures have persisted more than three months after prescribed therapy
began.
B. Minor motor seizures. Classical petit mal seizures must be
documented by characteristic EEG pattern, plus information as to age at
onset and frequency of clinical seizures. Myoclonic seizures, whether of
the typical infantile or Lennox-gastaut variety after infancy, must also
be documented by the characteristic EEG pattern plus information as to
age at onset and frequency of seizures.
C. Motor dysfunction. As described in 111.06, motor dysfunction may
be due to any neurological disorder. It may be due to static or
progressive conditions involving any area of the nervous system and
producing any type of neurological impairment. This may include
weakness, spasticity, lack of coordination, ataxia, tremor, athetosis,
or sensory loss. Documentation of motor dysfunction must include
neurologic findings and description of type of neurologic abnormality
(e.g., spasticity, weakness), as well as a description of the child's
functional impairment (i.e., what the child is unable to do because of
the abnormality). Where a diagnosis has been made, evidence should be
included for substantiation of the diagnosis (e.g., blood chemistries
and muscle biopsy reports), wherever applicable.
D. Impairment of communication. The documentation should include a
description of a recent comprehensive evaluation, including all areas of
affective and effective communication, performed by a qualified
professional.
111.01 Category of Impairment, Neurological
111.02 Major motor seizure disorder.
A. Major motor seizures. In a child with an established seizure
disorder, the occurrence of more than one major motor seizure per month
despite at least three months of prescribed treatment. With:
1. Daytime episodes (loss of consciousness and convulsive seizures);
or
2. Nocturnal episodes manifesting residuals which interfere with
activity during the day.
B. Major motor seizures. In a child with an established seizure
disorder, the occurrence of a least one major motor seizure in the year
prior to application despite at least three months of prescribed
treatment. And one of the following:
1. IQ of 70 or less; or

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2. Significant interference with communication due to speech,
hearing, or visual defect; or
3. Significant emotional disorder; or
4. Where significant adverse effects of medication interfere with
major daily activities.
111.03 Minor motor seizure disorder. In a child with an established
seizure disorder, the occurrence of more than one minor motor seizure
per week, with alteration of awareness or loss of consciousness, despite
at least three months of prescribed treatment.
111.05 Brain tumors. A. Malignant gliomas (astrocytoma--Grades III
and IV, glioblastoma multiforme), medulloblastoma, ependymoblastoma,
primary sarcoma or brain stem gliomas; or
B. Evaluate other brain tumors under the criteria for the resulting
neurological impairment.
111.06 Motor dysfunction (due to any neurological disorder).
Persistent disorganization or deficit of motor function for age
involving two extremities, which (despite prescribed therapy) interferes
with age-appropriate major daily activities and results in disruption
of:
A. Fine and gross movements; or
B. Gait and station.
111.07 Cerebral palsy. With:
A. Motor dysfunction meeting the requirements of 111.06 or 101.03;
or
B. Less severe motor dysfunction (but more than slight) and one of
the following:
1. IQ of 70 or less; or
2. Seizure disorder, with at least one major motor seizure in the
year prior to application; or
3. Significant interference with communication due to speech,
hearing or visual defect; or
4. Significant emotional disorder.
111.08 Meningomyelocele (and related disorders). With one of the
following despite prescribed treatment:
A. Motor dysfunction meeting the requirements of Sec. 101.03 or
Sec. 111.06; or
B. Less severe motor dysfunction (but more than slight), and:
1. Urinary or fecal incontinence when inappropriate for age; or
2. IQ of 70 or less; or
C. Four extremity involvement; or
D. Noncompensated hydrocephalus producing interference with mental
or motor developmental progression.
111.09 Communication impairment, associated with documented
neurological disorder. And one of the following:
A. Documented speech deficit which significantly affects the clarity
and content of the speech; or
B. Documented comprehension deficit resulting in ineffective verbal
communication for age; or
C. Impairment of hearing as described under the criteria in 102.08.

112.00 Mental Disorders

A. Introduction: The structure of the mental disorders listings for
children under age 18 parallels the structure for the mental disorders
listings for adults but is modified to reflect the presentation of
mental disorders in children. The listings for mental disorders in
children are arranged in 11 diagnostic categories: Organic mental
disorders (112.02); schizophrenic, delusional (paranoid),
schizoaffective, and other psychotic disorders (112.03); mood disorders
(112.04); mental retardation (112.05); anxiety disorders (112.06);
somatoform, eating, and tic disorders (112.07); personality disorders
(112.08); psychoactive substance dependence disorders (112.09); autistic
disorder and other pervasive developmental disorders (112.10); attention
deficit hyperactivity disorder (112.11); and developmental and emotional
disorders of newborn and younger infants (112.12).
There are significant differences between the listings for adults
and the listings for children. There are disorders found in children
that have no real analogy in adults; hence, the differences in the
diagnostic categories for children. The presentation of mental disorders
in children, particularly the very young child, may be subtle and of a
character different from the signs and symptoms found in adults. For
example, findings such as separation anxiety, failure to mold or bond
with the parents, or withdrawal may serve as findings comparable to
findings that mark mental disorders in adults. The activities
appropriate to children, such as learning, growing, playing, maturing,
and school adjustment, are also different from the activities
appropriate to the adult and vary widely in the different childhood
stages.
Each listing begins with an introductory statement that describes
the disorder or disorders addressed by the listing. This is followed
(except in listings 112.05 and 112.12) by medical findings (paragraph A
criteria), which, if satisfied, lead to an assessment of impairment-
related functional limitations (paragraph B criteria). An individual
will be found to have a listed impairment when the criteria of both
paragraphs A and B of the listed impairment are satisfied.
The purpose of the criteria in paragraph A is to substantiate
medically the presence of a particular mental disorder. Specific
symptoms and signs under any of the listings 112.02 through 112.12
cannot be considered in isolation from the description of the mental
disorder contained at the beginning of each listing category.
Impairments should be analyzed or reviewed under the mental
category(ies) indicated by the medical findings.

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Paragraph A of the listings is a composite of medical findings which
are used to substantiate the existence of a disorder and may or may not
be appropriate for children at specific developmental stages. However, a
range of medical findings is included in the listings so that no age
group is excluded. For example, in listing 112.02A7, emotional lability
and crying would be inappropriate criteria to apply to older infants and
toddlers, age 1 to attainment of age 3; whereas in 112.02A1,
developmental arrest, delay, or regression are appropriate criteria for
older infants and toddlers. Whenever the adjudicator decides that the
requirements of paragraph A of a particular mental listing are
satisfied, then that listing should be applied regardless of the age of
the child to be evaluated.
The purpose of the paragraph B criteria is to describe impairment-
related functional limitations which are applicable to children.
Standardized tests of social or cognitive function and adaptive behavior
are frequently available and appropriate for the evaluation of children
and, thus, such tests are included in the paragraph B functional
parameters. The functional restrictions in paragraph B must be the
result of the mental disorder which is manifested by the medical
findings in paragraph A.
We have not included separate C criteria for listings 112.03 and
112.06, as are found in the adult listings, because for the most part we
do not believe that categories like residual schizophrenia or
agoraphobia are commonly found in children. However, in unusual cases
where these disorders are found in children and are comparable to the
severity and duration found in adults, the adult 12.03C and 12.06C
criteria may be used for evaluation of the cases.
The structure of the listings for Mental Retardation (112.05) and
Developmental and Emotional Disorders of Newborn and Younger Infants
(112.12) is different from that of the other mental disorders. Listing
112.05 (Mental Retardation) contains six sets of criteria, any one of
which, if satisfied, will result in a finding that the child's
impairment meets the listing. Listing 112.12 (Developmental and
Emotional Disorders of Newborn and Younger Infants) contains five
criteria, any one of which, if satisfied, will result in a finding that
the infant's impairment meets the listing.
It must be remembered that these listings are examples of common
mental disorders which are severe enough to find a child disabled. When
a child has a medically determinable impairment that is not listed or a
combination of impairments no one of which meets a listing, we will make
a medical equivalency determination. (See Secs. 404.1526 and 416.926.)
This determination can be especially important in older infants and
toddlers (age 1 to attainment of age 3), who may be too young for
identification of a specific diagnosis, yet demonstrate serious
functional limitations. Therefore, the determination of equivalency is
necessary to the evaluation of any child's case when the child does not
have an impairment that meets a listing.
B. Need for Medical Evidence: The existence of a medically
determinable impairment of the required duration must be established by
medical evidence consisting of symptoms, signs, and laboratory findings
(including psychological or developmental test findings). Symptoms are
complaints presented by the child. Psychiatric signs are medically
demonstrable phenomena which indicate specific abnormalities of
behavior, affect, thought, memory, orientation, development, and contact
with reality, as described by an appropriate medical source. Symptoms
and signs generally cluster together to constitute recognizable mental
disorders described in paragraph A of the listings. These findings may
be intermittent or continuous depending on the nature of the disorder.
C. Assessment of Severity: In childhood cases, as with adults,
severity is measured according to the functional limitations imposed by
the medically determinable mental impairment. However, the range of
functions used to assess impairment severity for children varies at
different stages of maturation. The functional areas that we consider
are: Motor function; cognitive/communicative function; social function;
personal/behavioral function; and concentration, persistence, and pace.
In most functional areas, there are two alternative methods of
documenting the required level of severity: (1) Use of standardized
tests alone, where appropriate test instruments are available, and (2)
use of other medical findings. (See 112.00D for explanation of these
documentation requirements.) The use of standardized tests is the
preferred method of documentation if such tests are available.
Newborn and younger infants (birth to attainment of age 1) have not
developed sufficient personality differentiation to permit formulation
of appropriate diagnoses. We have, therefore, assigned listing 112.12
for Developmental and Emotional Disorders of Newborn and Younger Infants
for the evaluation of mental disorders of such children. Severity of
these disorders is based on measures of development in motor, cognitive/
communicative, and social functions. When older infants and toddlers
(age 1 to attainment of age 3) do not clearly satisfy the paragraph A
criteria of any listing because of insufficient developmental
differentiation, they must be evaluated under the rules for equivalency.
The principles for assessing the severity of impairment in such
children, described in the following paragraphs, must be employed.

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In defining the severity of functional limitations, two different
sets of paragraph B criteria corresponding to two separate age groupings
have been established, in addition to listing 112.12, which is for
children who have not attained age 1. These age groups are: older
infants and toddlers (age 1 to attainment of age 3) and children (age 3
to attainment of age 18). However, the discussion below in 112.00C1, 2,
3, and 4, on the age-appropriate areas of function, is broken down into
four age groupings: older infants and toddlers (age 1 to attainment of
age 3), preschool children (age 3 to attainment of age 6), primary
school children (age 6 to attainment of age 12), and adolescents (age 12
to attainment of age 18). This was done to provide specific guidance on
the age group variances in disease manifestations and methods of
evaluation.
Where ``marked'' is used as a standard for measuring the degree of
limitation it means more than moderate but less than extreme. A marked
limitation may arise when several activities or functions are impaired,
or even when only one is impaired, as long as the degree of limitation
is such as to interfere seriously with the ability to function (based
upon age-appropriate expectations) independently, appropriately,
effectively, and on a sustained basis. When standardized tests are used
as the measure of functional parameters, a valid score that is two
standard deviations below the norm for the test will be considered a
marked restriction.
1. Older infants and toddlers (age 1 to attainment of age 3). In
this age group, impairment severity is assessed in three areas: (a)
Motor development, (b) cognitive/communicative function, and (c) social
function.
a. Motor development. Much of what we can discern about mental
function in these children frequently comes from observation of the
degree of development of fine and gross motor function. Developmental
delay, as measured by a good developmental milestone history confirmed
by medical examination, is critical. This information will ordinarily be
available in the existing medical evidence from the claimant's treating
sources and other medical sources, supplemented by information from
nonmedical sources, such as parents, who have observed the child and can
provide pertinent historical information. It may also be available from
standardized testing. If the delay is such that the older infant or
toddler has not achieved motor development generally acquired by
children no more than one-half the child's chronological age, the
criteria are satisfied.
b. Cognitive/communicative function. Cognitive/communicative
function is measured using one of several standardized infant scales.
Appropriate tests for the measure of such function are discussed in
112.00D. Care should be taken to avoid reliance on screening devices,
which are not generally considered to be sufficiently reliable
instruments, although such devices may provide some relevant data;
however, there will be cases in which the results of such tests show
such severe abnormalities that further testing will be unnecessary.
For older infants and toddlers, alternative criteria covering
disruption in communication as measured by their capacity to use simple
verbal and nonverbal structures to communicate basic needs are provided.
c. Social function. Social function in older infants and toddlers is
measured in terms of the development of relatedness to people (e.g.,
bonding and stranger anxiety) and attachment to animate or inanimate
objects. Criteria are provided that use standard social maturity scales
or alternative criteria that describe marked impairment in
socialization.
2. Preschool children (age 3 to attainment of age 6). For the age
groups including preschool children through adolescence, the functional
areas used to measure severity are: (a) Cognitive/communicative
function, (b) social function, (c) personal/behavioral function, and (d)
deficiencies of concentration, persistence, or pace resulting in
frequent failure to complete tasks in a timely manner. After 36 months,
motor function is no longer felt to be a primary determinant of mental
function, although, of course, any motor abnormalities should be
documented and evaluated.
a. Cognitive/communicative function. In the preschool years and
beyond, cognitive function can be measured by standardized tests of
intelligence, although the appropriate instrument may vary with age. A
primary criterion for limited cognitive function is a valid verbal,
performance, or full scale IQ of 70 or less. The listings also provide
alternative criteria, consisting of tests of language development or
bizarre speech patterns.
b. Social function. Social function is measured by an assessment of
a child's relationships with parents, other adults, and peers. These
relationships are often observed not only at home but also in preschool
programs, where the child's interactions with other children and
teachers come under daily scrutiny.
c. Personal/behavioral function. This function may be measured by a
standardized test of adaptive behavior or by careful description of
maladaptive or avoidant behaviors. These behaviors are often observed
not only at home but also in preschool programs.
d. Concentration, persistence, and pace. This function may be
measured through observations of the child in the course of standardized
testing and in the course of play.
3. Primary school children (age 6 to attainment of age 12). The
measures of function here are similar to those for preschool-age
children except that the test instruments

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may change and the capacity to function in the school setting is
supplemental information. Standardized measures of academic achievement,
e.g., Wide Range Achievement Test-Revised, Peabody Individual
Achievement Test, etc., may be helpful in assessing cognitive
impairment. Problems in social functioning, especially in the area of
peer relationships, are often observed firsthand by teachers and school
nurses. As described in 112.00D, Documentation, school records are an
excellent source of information concerning function and standardized
testing and should always be sought for school-age children.
As it applies to primary school children, the intent of the
functional criterion described in paragraph B2d, i.e., deficiencies of
concentration, persistence, or pace resulting in failure to complete
tasks in a timely manner, is to identify the child who cannot adequately
function in primary school because of a mental impairment. Although
grades and the need for special education placement are relevant factors
which must be considered in reaching a decision under paragraph B2d,
they are not conclusive. There is too much variability from school
district to school district in the expected level of grading and in the
criteria for special education placement to justify reliance solely on
these factors.
4. Adolescents (age 12 to attainment of age 18). Functional criteria
parallel to those for primary school children (cognitive/communicative;
social; personal/behavioral; and concentration, persistence, and pace)
are the measure of severity for this age group. Testing instruments
appropriate to adolescents should be used where indicated. Comparable
findings of disruption of social function must consider the capacity to
form appropriate, stable, and lasting relationships. If information is
available about cooperative working relationships in school or at part-
time or full-time work, or about the ability to work as a member of a
group, it should be considered when assessing the child's social and
personal/behavioral functioning. Markedly impoverished social contact,
isolation, withdrawal, and inappropriate or bizarre behavior under the
stress of socializing with others also constitute comparable findings.
In adolescents, the intent of the functional criterion described in
paragraph B2d is the same as in primary school children. However, other
evidence of this functional impairment may also be available, such as
from evidence of the child's performance in work or work-like settings.
D. Documentation: The presence of a mental disorder in a child must
be documented on the basis of reports from acceptable sources of medical
evidence. See Secs. 404.1513 and 416.913. Descriptions of functional
limitations may be available from these sources, either in the form of
standardized test results or in other medical findings supplied by the
sources, or both. (Medical findings consist of symptoms, signs, and
laboratory findings.) Whenever possible, a medical source's findings
should reflect the medical source's consideration of information from
parents or other concerned individuals who are aware of the child's
activities of daily living, social functioning, and ability to adapt to
different settings and expectations, as well as the medical source's
findings and observations on examination, consistent with standard
clinical practice. As necessary, information from nonmedical sources,
such as parents, should also be used to supplement the record of the
child's functioning to establish the consistency of the medical evidence
and longitudinality of impairment severity.
For some newborn and younger infants, it may be very difficult to
document the presence or severity of a mental disorder. Therefore, with
the exception of some genetic diseases and catastrophic congenital
anomalies, it may be necessary to defer making a disability decision
until the child attains 3 months of age in order to obtain adequate
observation of behavior or affect. See, also, 110.00 of this part. This
period could be extended in cases of premature infants depending on the
degree of prematurity and the adequacy of documentation of their
developmental and emotional status.
For infants and toddlers, programs of early intervention involving
occupational, physical, and speech therapists, nurses, social workers,
and special educators, are a rich source of data. They can provide the
developmental milestone evaluations and records on the fine and gross
motor functioning of these children. This information is valuable and
can complement the medical examination by a physician or psychologist. A
report of an interdisciplinary team that contains the evaluation and
signature of an acceptable medical source is considered acceptable
medical evidence rather than supplemental data.
In children with mental disorders, particularly those requiring
special placement, school records are a rich source of data, and the
required reevaluations at specified time periods can provide the
longitudinal data needed to trace impairment progression over time.
In some cases where the treating sources lack expertise in dealing
with mental disorders of children, it may be necessary to obtain
evidence from a psychiatrist, psychologist, or pediatrician with
experience and skill in the diagnosis and treatment of mental disorders
as they appear in children. In these cases, however, every reasonable
effort must be made to obtain the records of the treating sources, since
these records will help establish a longitudinal picture that cannot be
established through a single purchased examination.

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A reference to standardized psychological testing indicates the use
of a psychological test that has appropriate characertistics of
validity, reliability, and norms, administered individually by
psychologist, psychiatrist, pediatrician, or other physician specialist
qualified by training and experience to perform such an evaluation.
Psychological tests are best considered as sets of tasks or questions
designed to elicit particular behaviors when presented in a standardized
manner.
The salient characteristics of a good test are: (1) Validity, i.e.,
the test measures what it is supposed to measure, as determined by
appropriate methods; (2) reliability, i.e., the consistency of results
obtained over time with the same test and the same individual; and (3)
appropriate normative data, i.e., individual test scores must be
comparable to test data from other individuals or groups of a similar
nature, representative of that population. In considering the validity
of a test result, any discrepancies between formal test results and the
child's customary behavior and daily activities should be duly noted and
resolved.
Tests meeting the above requirements are acceptable for the
determination of the conditions contained in these listings. The
psychologist, psychiatrist, pediatrician, or other physician specialist
administering the test must have a sound technical and professional
understanding of the test and be able to evaluate the research
documentation related to the intended application of the test.
Identical IQ scores obtained from different tests do not always
reflect a similar degree of intellectual functioning. The IQ scores in
listing 112.05 reflect values from tests of general intelligence that
have a mean of 100 and a standard deviation of 15, e.g., the Wechsler
series and the Revised Stanford-Binet scales. Thus, IQ's below 60
reflect a level of intellectual functioning below 99.5 percent of the
general population, and IQ's of 70 and below are characteristic of
approximately the lowest 2 percent of the general population. IQ's
obtained from standardized tests that deviate significantly from a mean
of 100 and standard deviation of 15 require conversion to the
corresponding percentile rank in the general population so that the
actual degree of impairment reflected by the IQ scores can be
determined. In cases where more than one IQ is customarily derived from
the test administered, e.g., where verbal, performance, and full scale
IQ's are provided, as on the Wechsler series, the lowest of these is
used in conjunction with listing 112.05.
IQ test results must also be sufficiently current for accurate
assessment under 112.05. Generally, the results of IQ tests tend to
stabilize by the age of 16. Therefore, IQ test results obtained at age
16 or older should be viewed as a valid indication of the child's
current status, provided they are compatible with the child's current
behavior. IQ test results obtained between ages 7 and 16 should be
considered current for 4 years when the tested IQ is less than 40, and
for 2 years when the IQ is 40 or above. IQ test results obtained before
age 7 are current for 2 years if the tested IQ is less than 40 and 1
year if at 40 or above.
Standardized intelligence test results are essential to the
adjudication of all cases of mental retardation that are not covered
under the provisions of listings 112.05A, 112.05B, and 112.05F. Listings
112.05A, 112.05B, and 112.05F may be the bases for adjudicating cases
where the results of standardized intelligence tests are unavailable,
e.g., where the child's young age or condition precludes formal
standardized testing.
In conjunction with clinical examinations, sources may report the
results of screening tests, i.e., tests used for gross determination of
level of functioning. These tests do not have high validity and
reliability and generally are not considered appropriate primary
evidence for disability determinations. These screening instruments may
be useful in uncovering potentially serious impairments, but generally
must be supplemented by the use of formal, standardized psychological
testing for the purposes of a disability determination, unless the
determination is to be made on the basis of findings other than
psychological test data; however, there will be cases in which the
results of screening tests show such obvious abnormalities that further
testing will clearly be unnecessary.
Where reference is made to developmental milestones, this is defined
as the attainment of particular mental or motor skills at an age-
appropriate level, i.e., the skills achieved by an infant or toddler
sequentially and within a given time period in the motor and
manipulative areas, in general understanding and social behavior, in
self-feeding, dressing, and toilet training, and in language. This is
sometimes expressed as a developmental quotient (DQ), the relation
between developmental age and chronological age as determined by
specific standardized measurements and observations. Such tests include,
but are not limited to, the Cattell Infant Intelligence Scale, the
Bayley Scales of Infant Development, and the Revised Stanford-Binet.
Formal tests of the attainment of developmental milestones are generally
used in the clinical setting for determination of the developmental
status of infants and toddlers.
Formal psychological tests of cognitive functioning are generally in
use for preschool children, for primary school children, and for
adolescents except for those instances noted below.
Exceptions to formal standardized psychological testing may be
considered when a psychologist, psychiatrist, pediatrician, or

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other physician specialist who is qualified by training and experience
to perform such an evaluation is not readily available. In such
instances, appropriate medical, historical, social, and other
information must be reviewed in arriving at a determination.
Exceptions may also be considered in the case of ethnic/cultural
minorities where the native language or culture is not principally
English-speaking. In such instances, psychological tests that are
culture-free, such as the Leiter International Performance Scale or the
Scale of Multi-Culture Pluralistic Assessment (SOMPA) may be substituted
for the standardized tests described above. Any required tests must be
administered in the child's principal language. When this is not
possible, appropriate medical, historical, social, and other information
must be reviewed in arriving at a determination. Furthermore, in
evaluating mental impairments in children from a different culture, the
best indicator of severity is often the level of adaptive functioning
and how the child performs activities of daily living and social
functioning.
Neuropsychological testing refers to the administration of
standardized tests that are reliable and valid with respect to assessing
impairment in brain functioning. It is intended that the psychologist or
psychiatrist using these tests will be able to evaluate the following
functions: Attention/concentration, problem-solving, language, memory,
motor, visual-motor and visual-perceptual, laterality, and general
intelligence (if not previously obtained).
E. Effect of Hospitalization or Residential Placement: As with
adults, children with mental disorders may be placed in a variety of
structured settings outside the home as part of their treatment. Such
settings include, but are not limited to, psychiatric hospitals,
developmental disabilities facilities, residential treatment centers and
schools, community-based group homes, and workshop facilities. The
reduced mental demands of such structured settings may attenuate overt
symptomatology and superficially make the child's level of adaptive
functioning appear better than it is. Therefore, the capacity of the
child to function outside highly structured settings must be considered
in evaluating impairment severity. This is done by determining the
degree to which the child can function (based upon age-appropriate
expectations) independently, appropriately, effectively, and on a
sustained basis outside the highly structured setting.
On the other hand, there may be a variety of causes for placement of
a child in a structured setting which may or may not be directly related
to impairment severity and functional ability. Placement in a structured
setting in and of itself does not equate with a finding of disability.
The severity of the impairment must be compared with the requirements of
the appropriate listing.
F. Effects of Medication: Attention must be given to the effect of
medication on the child's signs, symptoms, and ability to function.
While psychoactive medications may control certain primary
manifestations of a mental disorder, e.g., hallucinations, impaired
attention, restlessness, or hyperactivity, such treatment may or may not
affect the functional limitations imposed by the mental disorder. In
cases where overt symptomatology is attenuated by the psychoactive
medications, particular attention must be focused on the functional
limitations which may persist. These functional limitations must be
considered in assessing impairment severity.
Psychotropic medicines used in the treatment of some mental
illnesses may cause drowsiness, blunted affect, or other side effects
involving other body systems. Such side effects must be considered in
evaluating overall impairment severity.

112.01 Category of Impairments, Mental

112.02 Organic Mental Disorders: Abnormalities in perception,
cognition, affect, or behavior associated with dysfunction of the brain.
The history and physical examination or laboratory tests, including
psychological or neuropsychological tests, demonstrate or support the
presence of an organic factor judged to be etiologically related to the
abnormal mental state and associated deficit or loss of specific
cognitive abilities, or affective changes, or loss of previously
acquired functional abilities.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented persistence of at least one of the
following:
1. Developmental arrest, delay or regression; or
2. Disorientation to time and place; or
3. Memory impairment, either short-term (inability to learn new
information), intermediate, or long-term (inability to remember
information that was known sometime in the past); or
4. Perceptual or thinking disturbance (e.g., hallucinations,
delusions, illusions, or paranoid thinking); or
5. Disturbance in personality (e.g., apathy, hostility); or
6. Disturbance in mood (e.g., mania, depression); or
7. Emotional lability (e.g., sudden crying); or
8. Impairment of impulse control (e.g., disinhibited social
behavior, explosive temper outbursts); or
9. Impairment of cognitive function, as measured by clinically
timely standardized psychological testing; or

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10. Disturbance of concentration, attention, or judgment;

AND

B. Select the appropriate age group to evaluate the severity of the
impairment:
1. For older infants and toddlers (age 1 to attainment of age 3),
resulting in at least one of the following:
a. Gross or fine motor development at a level generally acquired by
children no more than one-half the child's chronological age, documented
by:
(1) An appropriate standardized test; or
(2) Other medical findings (see 112.00C); or
b. Cognitive/communicative function at a level generally acquired by
children no more than one-half the child's chronological age, documented
by:
(1) An appropriate standardized test; or
(2) Other medical findings of equivalent cognitive/communicative
abnormality, such as the inability to use simple verbal or nonverbal
behavior to communicate basic needs or concepts; or
c. Social function at a level generally acquired by children no more
than one-half the child's chronological age, documented by:
(1) An appropriate standardized test; or
(2) Other medical findings of an equivalent abnormality of social
functioning, exemplified by serious inability to achieve age-appropriate
autonomy as manifested by excessive clinging or extreme separation
anxiety; or
d. Attainment of development or function generally acquired by
children no more than two-thirds of the child's chronological age in two
or more areas covered by a., b., or c., as measured by an appropriate
standardized test or other appropriate medical findings.
2. For children (age 3 to attainment of age 18), resulting in at
least two of the following:
a. Marked impairment in age-appropriate cognitive/communicative
function, documented by medical findings (including consideration of
historical and other information from parents or other individuals who
have knowledge of the child, when such information is needed and
available) and including, if necessary, the results of appropriate
standardized psychlogical tests, or for children under age 6, by
appropriate tests of language and communication; or
b. Marked impairment in age-appropriate social functioning,
documented by history and medical findings (including consideration of
information from parents or other individuals who have knowledge of the
child, when such information is needed and available) and including, if
necessary, the results of appropriate standardized tests; or
c. Marked impairment in personal/behavioral function, as evidenced
by:
(1) Marked restriction of age-appropriate activities of daily
living, documented by history and medical findings (including
consideration of information from parents or other individuals who have
knowledge of the child, when such information is needed and available)
and including, if necessary, appropriate standardized tests; or
(2) Persistent serious maladaptive behaviors destructive to self,
others, animals, or property, requiring protective intervention; or
d. Deficiencies of concentration, persistence, or pace resulting in
frequent failure to complete tasks in a timely manner.
112.03 Schizophrenic, Delusional (Paranoid), Schizoaffective, and
Other Psychotic Disorders: Onset of psychotic features, characterized by
a marked disturbance of thinking, feeling, and behavior, with
deterioration from a previous level of functioning or failure to achieve
the expected level of social functioning.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented persistence, for at least 6 months, either
continuous or intermittent, of one or more of the following:
1. Delusions or hallucinations; or
2. Catatonic, bizarre, or other grossly disorganized behavior; or
3. Incoherence, loosening of associations, illogical thinking, or
poverty of content of speech; or
4. Flat, blunt, or inappropriate affect; or
5. Emotional withdrawal, apathy, or isolation;

AND

B. For older infants and toddlers (age 1 to attainment of age 3),
resulting in at least one of the appropriate age-group criteria in
paragraph B1 of 112.02; or, for children (age 3 to attainment of age
18), resulting in at least two of the appropriate age-group criteria in
paragraph B2 of 112.02.
112.04 Mood Disorders: Characterized by a disturbance of mood
(referring to a prolonged emotion that colors the whole psychic life,
generally involving either depression or elation), accompanied by a full
or partial manic or depressive syndrome.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented persistence, either continuous or
intermittent, of one of the following:
1. Major depressive syndrome, characterized by at least five of the
following, which must include either depressed or irritable mood or
markedly diminished interest or pleasure:
a. Depressed or irritable mood; or
b. Markedly diminished interest or pleasure in almost all
activities; or
c. Appetite or weight increase or decrease, or failure to make
expected weight gains; or
d. Sleep disturbance; or

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e. Psychomotor agitation or retardation; or
f. Fatigue or loss of energy; or
g. Feelings of worthlessness or guilt; or
h. Difficulty thinking or concentrating; or
i. Suicidal thoughts or acts; or
j. Hallucinations, delusions, or paranoid thinking;

2. Manic syndrome, characterized by elevated, expansive, or
irritable mood, and at least three of the following:
a. Increased activity or psychomotor agitation; or
b. Increased talkativeness or pressure of speech; or
c. Flight of ideas or subjectively experienced racing thoughts; or
d. Inflated self-esteem or grandiosity; or
e. Decreased need for sleep; or
f. Easy distractibility; or
g. Involvement in activities that have a high potential of painful
consequences which are not recognized; or
h. Hallucinations, delusions, or paranoid thinking;

3. Bipolar or cyclothymic syndrome with a history of episodic
periods manifested by the full symptomatic picture of both manic and
depressive syndromes (and currently or most recently characterized by
the full or partial symptomatic picture of either or both syndromes);

AND

B. Mental incapacity evidenced by dependence upon others for
personal needs (grossly in excess of age-appropriate dependence) and
inability to follow directions such that the use of standardized
measures of intellectual functioning is precluded;

C. A valid verbal, performance, or full scale IQ of 59 or less;

D. A valid verbal, performance, or full scale IQ of 60 through 70
and a physical or other mental impairment imposing additional and
significant limitation of function;

E. A valid verbal, performance, or full scale IQ of 60 through 70
and:
1. For older infants and toddlers (age 1 to attainment of age 3),
resulting in attainment of development or function generally acquired by
children no more than two-thirds of the child's chronological age in
either paragraphs B1a or B1c of 112.02; or
2. For children (age 3 to attainment of age 18), resulting in at
least one of paragraphs B2b or B2c or B2d of 112.02;

F. Select the appropriate age group:
1. For older infants and toddlers (age 1 to attainment of age 3),
resulting in attainment of development or function generally acquired by
children no more than two-thirds of the child's chronological age in
paragraph B1b of 112.02, and a physical or other mental impairment
imposing additional and significant limitations of function;

2. For children (age 3 to attainment of age 18), resulting in the
satisfaction of 112.02B2a, and a physical or other mental impairment
imposing additional and significant limitations of function.
112.06 Anxiety Disorders: In these disorders, anxiety is either the
predominant disturbance or is experienced if the individual attempts to
master symptoms, e.g., confronting the dreaded object or situation in a
phobic disorder, attempting to go to school in a separation anxiety
disorder, resisting the obsessions or compulsions in an obsessive
compulsive disorder, or confronting strangers or peers in avoidant
disorders.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented findings of at least one of the following:
1. Excessive anxiety manifested when the child is separated, or
separation is threatened, from a parent or parent surrogate; or
2. Excessive and persistent avoidance of strangers; or
3. Persistent unrealistic or excessive anxiety and worry
(apprehensive expectation), accompanied by motor tension, autonomic
hyperactivity, or vigilance and scanning; or
4. A persistent irrational fear of a specific object, activity, or
situation which results in a compelling desire to avoid the dreaded
object, activity, or situation; or

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5. Recurrent severe panic attacks, manifested by a sudden
unpredictable onset of intense apprehension, fear, or terror, often with
a sense of impending doom, occurring on the average of at least once a
week; or
6. Recurrent obsessions or compulsions which are a source of marked
distress; or
7. Recurrent and intrusive recollections of a traumatic experience,
including dreams, which are a source of marked distress;

AND

B. For older infants and toddlers (age 1 to attainment of age 3),
resulting in at least one of the appropriate age-group criteria in
paragraph B1 of 112.02; or, for children (age 3 to attainment of age
18), resulting in at least two of the appropriate age-group criteria in
paragraph B2 of 112.02.
112.07 Somatoform, Eating, and Tic Disorders: Manifested by
physical symptoms for which there are no demonstrable organic findings
or known physiologic mechanisms; or eating or tic disorders with
physical manifestations.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented findings of one of the following:
1. An unrealistic fear and perception of fatness despite being
underweight, and persistent refusal to maintain a body weight which is
greater than 85 percent of the average weight for height and age, as
shown in the most recent edition of the Nelson Textbook of Pediatrics,
Richard E. Behrman and Victor C. Vaughan, III, editors, Philadelphia: W.
B. Saunders Company; or
2. Persistent and recurrent involuntary, repetitive, rapid,
purposeless motor movements affecting multiple muscle groups with
multiple vocal tics; or
3. Persistent nonorganic disturbance of one of the following:
a. Vision; or
b. Speech; or
c. Hearing; or
d. Use of a limb; or
e. Movement and its control (e.g., coordination disturbance,
psychogenic seizures); or
f. Sensation (diminished or heightened); or
g. Digestion or elimination; or
4. Preoccupation with a belief that one has a serious disease or
injury;

AND

B. For older infants and toddlers (age 1 to attainment of age 3),
resulting in at least one of the appropriate age-group criteria in
paragraph B1 of 112.02; or, for children (age 3 to attainment of age
18), resulting in at least two of the appropriate age-group criteria in
paragraph B2 of 112.02.
112.08 Personality Disorders: Manifested by pervasive, inflexible,
and maladaptive personality traits, which are typical of the child's
long-term functioning and not limited to discrete episodes of illness.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Deeply ingrained, maladaptive patterns of behavior, associated
with one of the following:
1. Seclusiveness or autistic thinking; or
2. Pathologically inappropriate suspiciousness or hostility; or
3. Oddities of thought, perception, speech, and behavior; or
4. Persistent disturbances of mood or affect; or
5. Pathological dependence, passivity, or aggressiveness; or
6. Intense and unstable interpersonal relationships and impulsive
and exploitative behavior; or
7. Pathological perfectionism and inflexibility;

AND

B. For older infants and toddlers (age 1 to attainment of age 3),
resulting in at least one of the appropriate age-group criteria in
paragraph B1 of 112.02; or, for children (age 3 to attainment of age
18), resulting in at least two of the appropriate age-group criteria in
paragraph B2 of 112.02.
112.09 Psychoactive Substance Dependence Disorders: Manifested by a
cluster of cognitive, behavioral, and physiologic symptoms that indicate
impaired control of psychoactive substance use with continued use of the
substance despite adverse consequences.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented findings of at least four of the following:
1. Substance taken in larger amounts or over a longer period than
intended and a great deal of time is spent in recovering from its
effects; or
2. Two or more unsuccessful efforts to cut down or control use; or
3. Frequent intoxication or withdrawal symptoms interfering with
major role obligations; or
4. Continued use despite persistent or recurring social,
psychological, or physical problems; or
5. Tolerance, as characterized by the requirement for markedly
increased amounts of substance in order to achieve intoxication; or
6. Substance taken to relieve or avoid withdrawal symptoms;

AND

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two of the appropriate age-group criteria in paragraph B2 of 112.02.
112.10 Autistic Disorder and Other Pervasive Developmental
Disorders: Characterized by qualitative deficits in the development of
reciprocal social interaction, in the development of verbal and
nonverbal communication skills, and in imaginative activity. Often,
there is a markedly restricted repertoire of activities and interests,
which frequently are stereotyped and repetitive.
The required level of severity for these disorders is met when the
requirements in both A and B are satisfied.
A. Medically documented findings of the following:
1. For autistic disorder, all of the following:
a. Qualitative deficits in the development of reciprocal social
interaction; and
b. Qualitative deficits in verbal and nonverbal communication and in
imaginative activity; and
c. Markedly restricted repertoire of activities and interests;

2. For pervasive developmental disorders, both of the following:
a. Qualitative deficits in the development of social interaction;
and
b. Qualitative deficits in verbal and nonverbal communication and in
imaginative activity;

AND

B. For older infants and toddlers (age 1 to attainment of age 3),
resulting in at least one of the appropriate age-group criteria in
paragraph B1 of 112.02; or, for children (age 3 to attainment of age
18), resulting in at least two of the appropriate age-group criteria in
paragraph B2 of 112.02.
112.12 Developmental and Emotional Disorders of Newborn and Younger
Infants (Birth to attainment of age 1): Developmental or emotional
disorders of infancy are evidenced by a deficit or lag in the areas of
motor, cognitive/communicative, or social functioning. These disorders
may be related either to organic or to functional factors or to a
combination of these factors.
The required level of severity for these disorders is met when the
requirements of A, B, C, D, or E are satisfied.
A. Cognitive/communicative functioning generally acquired by
children no more than one-half the child's chronological age, as
documented by appropriate medical findings (e.g., in infants 0-6 months,
markedly diminished variation in the production or imitation of sounds
and severe feeding abnormality, such as problems with sucking
swallowing, or chewing) including, if necessary, a standardized test;

B. Motor development generally acquired by children no more than
one-half the child's chronological age, documented by appropriate
medical findings, including if necessary, a standardized test;

C. Apathy, over-excitability, or fearfulness, demonstrated by an
absent or grossly excessive response to one of the following:
1. Visual stimulation; or
2. Auditory stimulation; or
3. Tactile stimulation;

D. Failure to sustain social interaction on an ongoing, reciprocal
basis as evidenced by:
1. Inability by 6 months to participate in vocal, visual, and
motoric exchanges (including facial expressions); or
2. Failure by 9 months to communicate basic emotional responses,
such as cuddling or exhibiting protest or anger; or
3. Failure to attend to the caregiver's voice or face or to explore
an inanimate object for a period of time appropriate to the infant's
age;

E. Attainment of development or function generally acquired by
children no more than two-thirds of the child's chronological age in two
or more areas (i.e., cognitive/communicative, motor, and social),
documented by appropriate medical findings, including if necessary,
standardized testing.

113.00 Neoplastic Diseases, Malignant

A. Introduction. Determination of disability in the growing and
developing child with a malignant neoplastic disease is based upon the
combined effects of:
1. The pathophysiology, histology, and natural history of the tumor;
and
2. The effects of the currently employed aggressive multimodal
therapeutic regimens.
Combinations of surgery, radiation, and chemotherapy or prolonged
therapeutic

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schedules impart significant additional morbidity to the child during
the period of greatest risk from the tumor itself. This period of
highest risk and greatest therapeutically-induced morbidity defines the
limits of disability for most of childhood neoplastic disease.
B. Documentation. The diagnosis of neoplasm should be established on
the basis of symptoms, signs, and laboratory findings. The site of the
primary, recurrent, and metastatic lesion must be specified in all cases
of malignant neoplastic diseases. If an operative procedure has been
performed, the evidence should include a copy of the operative note and
the report of the gross and microscopic examination of the surgical
specimen, along with all pertinent laboratory and X-ray reports. The
evidence should also include a recent report directed especially at
describing whether there is evidence of local or regional recurrence,
soft part or skeletal metastases, and significant post therapeutic
residuals.
C. Malignant solid tumors, as listed under 113.03, include the
histiocytosis syndromes except for solitary eosinophilic granuloma.
Thus, 113.03 should not be used for evaluating brain tumors (see 111.05)
or thyroid tumors, which must be evaluated on the basis of whether they
are controlled by prescribed therapy.
D. Duration of disability from malignant neoplastic tumors is
included in 113.02 and 113.03. Following the time periods designated in
these sections, a documented diagnosis itself is no longer sufficient to
establish a severe impairment. The severity of a remaining impairment
must be evaluated on the basis of the medical evidence.
113.01 Category of Impairments, Neoplastic Diseases--Malignant
113.02 Lymphoreticular malignant neoplasms.
A. Hodgkin's disease with progressive disease not controlled by
prescribed therapy; or
B. Non-Hodgkin's lymphoma. Consider under a disability:
1. For 2\1/2\ years from time of initial diagnosis; or
2. For 2\1/2\ years from time of recurrence of active disease.
113.03 Malignant solid tumors. Consider under a diability:
A. For 2 years from the time of initial diagnosis; or
B. For 2 years from the time of recurrence of active disease.
113.04 Neuroblastoma. With one of the following:
A. Extension across the midline; or
B. Distant metastases; or
C. Recurrence; or
D. Onset at age 1 year or older.
113.05 Retinoblastoma. With one of the following:
A. Bilateral involvement; or
B. Metastases; or
C. Extension beyond the orbit; or
D. Recurrence.

114.00 Immune System

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1. Allergic disorders (e.g., asthma or atopic dermatitis) are
discussed and evaluated under the appropriate listing of the affected
body system.
2. If growth is affected by the disorder or its treatment by
immunosuppressive drugs, 100.00 may apply.
3. Kawasaki disease, also known as mucocutaneous lymph node
syndrome, is characterized by multisystem manifestations, but
significant functional impairment is usually due to disease of the
coronary arteries, which should be evaluated under 104.00.
D. Human immunodeficiency virus (HIV) infection.
1. HIV infection is caused by a specific retrovirus and may be
characterized by susceptibility to one or more opportunistic diseases,
cancers, or other conditions, as described in 114.08. Any child with HIV
infection, including one with a diagnosis of acquired immunodeficiency
syndrome (AIDS), may be found disabled under this listing if his or her
impairment meets any of the criteria in 114.08 or is of equivalent
severity to an impairment in 114.08.
2. Definitions. In 114.08, the terms ``resistant to treatment,''
``recurrent,'' and ``disseminated'' have the same general meaning as
used by the medical community. The precise meaning of any of these terms
will depend upon the specific disease or condition in question, the body
system affected, the usual course of the disorder and its treatment, and
the other circumstances of the case.
``Resistant to treatment'' means that a condition did not respond
adequately to an appropriate course of treatment. Whether a response is
adequate, or a course of treatment appropriate, will depend on the facts
of the particular case.
``Recurrent'' means that a condition that responded adequately to an
appropriate course of treatment has returned after a period of remission
or regression. The extent of response (or remission) and the time
periods involved will depend on the facts of the particular case.
``Disseminated'' means that a condition is spread widely over a
considerable area or body system(s). The type and extent of the spread
will depend on the specific disease.
3. Documentation of HIV infection in children. The medical evidence
must include documentation of HIV infection. Documentation may be by
laboratory evidence or by other generally acceptable methods consistent
with the prevailing state of medical knowledge and clinical practice.
a. Documentation of HIV infection in children by definitive
diagnosis. A definitive diagnosis of HIV infection in children is
documented by one or more of the following laboratory tests:
i. For a child 24 months of age or older, a serum specimen that
contains HIV antibodies. HIV antibodies are usually detected by a
screening test. The most commonly used screening test is the ELISA.
Although this test is highly sensitive, it may yield false positive
results. Therefore, positive results from an ELISA must be confirmed by
a more definitive test (e.g., Western blot, immunofluorescence assay).
(See paragraph b, below, for information about HIV antibody testing in
children younger than 24 months of age).
ii. A specimen that contains HIV antigen (e.g., serum specimen,
lymphocyte culture, or cerebrospinal fluid (CSF) specimen).
iii. An immunoglobulin A (IgA) serological assay specific for HIV.
iv. Other test(s) that are highly specific for detection of HIV in
children (e.g., polymerase chain reaction (PCR)), or that are acceptable
methods of detection consistent with the prevailing state of medical
knowledge.
When laboratory testing for HIV infection has been performed, every
reasonable effort must be made to obtain reports of the results of that
testing.
b. Other acceptable documentation of HIV infection in children.
As noted in paragraph a, above, HIV infection is not documented in
children under 24 months of age by a serum specimen containing HIV
antibodies. This is because women with HIV infection often transfer HIV
antibodies to their newborns. The mother's antibodies can persist in the
infant for up to 24 months, even if the infant is not HIV-infected. Only
20 to 30 percent of such infants are actually infected. Therefore, the
presence of serum HIV antibodies alone does not establish the presence
of HIV infection in a child under 24 months of age. However, the
presence of HIV antibodies accompanied by evidence of significantly
depressed T-helper lymphocytes (CD4), an abnormal CD4/CD8 ratio, or
abnormal immunoglobulin G (IgG) may be used to document HIV infection in
a child under 24 months of age, even though such testing is not a basis
for a definitive diagnosis.
For children from birth to the attainment of 24 months of age who
have tested positive for HIV antibodies (see D3a above), HIV infection
may be documented by one or more of the following:
i. For an infant 12 months of age or less, a CD4 (T4) count of 1500/
mm\3\ or less, or a CD4 count less than or equal to 20 percent of total
lymphocytes.
ii. For an infant from 12 to 24 months of age, a CD4 (T4) count of
750/mm\3\ or less, or a CD4 count less than or equal to 20 percent of
total lymphocytes.
iii. An abnormal CD4/CD8 ratio.
iv. An IgG significantly greater than or less than the normal range
for age.

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HIV infection in children may also be documented without the
definitive laboratory evidence described in paragraph a, or the other
laboratory evidence discussed above, provided that such documentation is
consistent with the prevailing state of medical knowledge and clinical
practice and is consistent with the other evidence. If such laboratory
evidence is not available, HIV infection may be documented by the
medical history, clinical and laboratory findings, and diagnosis(es)
indicated in the medical evidence. For example, a diagnosis of HIV
infection in children will be accepted without definitive laboratory
evidence if the child has an opportunistic disease (e.g., Pneumocystis
carinii pneumonia (PCP)) predictive of a defect in cell-mediated
immunity, and there is no other known cause of diminished resistance to
that disease (e.g., long-term steroid treatment, lymphoma). In such
cases, every reasonable effort must be made to obtain full details of
the history, medical findings, and results of testing.
4. Documentation of the manifestations of HIV infection in children.
The medical evidence must also include documentation of the
manifestations of HIV infection in children. Documentation may be by
laboratory evidence or by other generally acceptable methods consistent
with the prevailing state of medical knowledge and clinical practice.
a. Documentation of the manifestations of HIV infection in children
by definitive diagnosis.
The definitive method of diagnosing opportunistic diseases or
conditions that are manifestations of HIV infection in children is by
culture, serological test, or microscopic examination of biopsied tissue
or other material (e.g., bronchial washings). Therefore, every
reasonable effort must be made to obtain specific laboratory evidence of
an opportunistic disease or other condition whenever this information is
available. If a histological or other test has been performed, the
evidence should include a copy of the appropriate report. If the report
is not obtainable, the summary of hospitalization or a report from the
treating source should include details of the findings and results of
the diagnostic studies (including radiographic studies) or microscopic
examination of the appropriate tissues or body fluids.
Although a reduced CD4 lymphocyte count in a child may show that
there is an increased susceptibility to opportunistic infections and
diseases, that alone does not document the presence, severity, or
functional effects of a manifestation of HIV infection in a child.
b. Other acceptable documentation of the manifestations of HIV
infection in children.
Manifestations of HIV infection in children may also be documented
without the definitive laboratory evidence described in paragraph a,
provided that such documentation is consistent with the prevailing state
of medical knowledge and clinical practice and is consistent with the
other evidence. If no definitive laboratory evidence is available,
manifestations of HIV infection may be documented by medical history,
clinical and laboratory findings, and diagnosis(es) indicated in the
medical evidence. In such cases, every reasonable effort must be made to
obtain full details of the history, medical findings, and results of
testing.
Documentation of cytomegalovirus (CMV) disease (114.08D) presents
special problems because diagnosis requires identification of viral
inclusion bodies or a positive culture from the affected organ, and the
absence of any other infectious agent. A positive serology test
identifies infection with the virus, but does not confirm a disease
process. With the exception of chorioretinitis (which may be diagnosed
by an ophthalmologist), documentation of CMV disease requires
confirmation by biopsy or other generally acceptable methods consistent
with the prevailing state of medical knowledge and clinical practice.
5. HIV infection in children. The clinical manifestation and course
of disease in children who become infected with HIV perinatally or in
the first 6 years of life may differ from that in older children and
adults. In addition, survival times are shorter for children infected in
the first year of life compared to those who become infected as older
children or as adults. Infants may present with failure to thrive or
pneumocystis carinii pneumonia (PCP); young children may present with
recurrent infections, neurological problems, or developmental
abnormalities. Older children may also exhibit neurological
abnormalities, such as HIV encephalopathy, or failure to thrive.
The methods of identifying and evaluating neurological abnormalities
may vary depending on a child's age. For example, in an infant, impaired
brain growth can be documented by a decrease in the growth rate of the
head. In older children, impaired brain growth can be documented by
brain atrophy on a CAT scan. Neurological abnormalities can also be
observed in a younger child in the loss of previously acquired, or
marked delays in achieving, developmental milestones. In an older child,
this type of neurological abnormality would generally be demonstrated by
the loss of previously acquired intellectual abilities. Although loss of
previously acquired intellectual abilities can be documented by a
decrease in intelligence quotient (IQ) scores or demonstrated if a child
forgets information he or she previously learned, it can also be shown
if the child is unable to learn new information. This could include the
sudden acquisition of a new learning disability.
Children with HIV infection may contract any of a broad range of
bacterial infections. Certain major infections caused by pyogenic

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bacteria, e.g., some pneumonias, can be severely limiting, especially in
pre-adolescent children. These major bacterial infections should be
evaluated under 114.08A5, which requires two or more such infections
within a 2-year period. Although 114.08A5 applies only to children less
than 13 years of age, an older child may be found to have an impairment
of equivalent severity if the circumstances of the case warrant (e.g.,
delayed puberty).
Otherwise, bacterial infections are evaluated under 114.08A6. The
criteria of the listing are met if one or more bacterial infection(s)
occurs and requires hospitalization or intravenous antibiotic treatment
3 or more times in 1 year. Pelvic inflammatory disease in older female
children should be evaluated under multiple or recurrent bacterial
infections (114.08A6).
6. Evaluation of HIV infection in children. The criteria in 114.08
do not describe the full spectrum of diseases or conditions manifested
by children with HIV infection. As in any case, consideration must be
given to whether a child's impairment(s) meets or equals in severity any
other listing in appendix 1 of subpart P (e.g., a neoplastic disorder
listed in 113.00ff). Although 114.08 includes cross-references to other
listings for the more common manifestations of HIV infection, additional
listings may also apply.
In addition, the impact of all impairments, whether or not related
to the HIV infection, must be considered. Children with HIV infection
may manifest signs and symptoms of a mental impairment (e.g., anxiety,
depression), or of another physical impairment. Medical evidence should
include documentation of all physical and mental impairments and the
impairment(s) should be evaluated not only under the relevant listing(s)
in 114.08, but under any other appropriate listing(s).
It is also important to remember that children with HIV infection,
like all others, are evaluated under the full sequential evaluation
process described in Sec. 416.924. If a child with HIV infection is
working and engaging in substantial gainful activity (SGA), or does not
have a severe impairment, the case will be decided at the first or
second step of the sequential evaluation process, and does not require
evaluation under these listings. For a child with HIV infection who is
not engaging in SGA and has a severe impairment, but whose impairment(s)
does not meet the criteria of a listing, consideration will be given to
whether the child's impairment or combination of impairments is either
medically or functionally equivalent in severity to any listed
impairment. If the child's impairment or impairments do not meet or
equal a listing in severity, evaluation must proceed through the final
step(s) of the sequential evaluation process (or, as appropriate, the
steps in the medical improvement review standard) before any conclusion
can be reached on the issue of disability.
7. Effect of treatment. Medical treatment must be considered in
terms of its effectiveness in ameliorating the signs, symptoms, and
laboratory abnormalities of the specific disorder, or of the HIV
infection itself (e.g. antiretroviral agents) and in terms of any side
effects of treatment that may further impair the child.
Response to treatment and adverse or beneficial consequences of
treatment may vary widely. For example, a child with HIV infection who
develops otitis media may respond to the same antibiotic regimen used in
treating children without HIV infection, but another child with HIV
infection may not respond to the same regimen. Therefore, each case must
be considered on an individual basis, along with the effects of
treatment on the child's ability to function.
A specific description of the drugs or treatment given (including
surgery), dosage, frequency of administration, and a description of the
complications or response to treatment should be obtained. The effects
of treatment may be temporary or long-term. As such, the decision
regarding the impact of treatment should be based on a sufficient period
of treatment to permit proper consideration.
8. Functional criteria. Paragraph O of 114.08 establishes standards
for evaluating manifestations of HIV infection that do not meet the
requirements listed in 114.08A-N. Paragraph O is applicable for
manifestations that are not listed in 114.08A-N, as well as those listed
in 114.08A-N that do not meet the criteria of any of the rules in
114.08A-N.
For children with HIV infection evaluated under 114.08O, listing-
level severity will be assessed in terms of the functional limitations
imposed by the impairment. The full impact of signs, symptoms, and
laboratory findings on the child's ability to function must be
considered. Important factors to be considered in evaluating the
functioning of children with HIV infection include, but are not limited
to: symptoms, such as fatigue and pain; characteristics of the illness,
such as the frequency and duration of manifestations or periods of
exacerbation and remission in the disease course; and the functional
impact of treatment for the disease, including the side effects of
medication.
To meet the criteria in 114.08O, a child with HIV infection must
demonstrate a level of restriction in either one or two (depending on
the child's age) of the general areas of functioning applicable to the
child's age group. (See 112.00C for additional discussion of these areas
of functioning).

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114.01 Category of Impairments, Immune System

114.02 Systemic lupus erythematosus. Documented as described in
14.00B1 and 114.00B, with:
A. One of the following:
1. Growth impairment, as described under the criteria in 100.00ff;
or
2. Musculoskeletal involvement, as described under the criteria in
101.00ff; or
3. Muscle involvement, as described under the criteria in 14.05; or
4. Ocular involvement, as described under the criteria in 102.00ff;
or
5. Respiratory involvement, as described under the criteria in
103.00ff; or
6. Cardiovascular involvement, as described under the criteria in
104.00ff or 14.04D; or
7. Digestive involvement, as described under the criteria in
105.00ff; or
8. Renal involvement, as described under the criteria in 106.00ff;
or
9. Hematologic involvement, as described under the criteria in
107.00ff; or
10. Skin involvement, as described under the criteria in 8.00ff; or
11. Endocrine involvement, as described under the criteria in
109.00ff; or
12. Neurological involvement, as described under the criteria in
111.00ff; or
13. Mental involvement, as described under the criteria in 112.00ff.

B. Lesser involvement of two or more organs/body systems listed in
paragraph A, with significant, documented, constitutional symptoms and
signs of severe fatigue, fever, malaise, and weight loss. At least one
of the organs/body systems must be involved to at least a moderate level
of severity.
114.03 Systemic vasculitis. As described under the criteria in
14.03 or, if growth impairment, as described under the criteria in
100.00ff.
114.04 Systemic sclerosis and scleroderma. Documented as described
in 14.00B3 and 114.00B, and:
A. As described under the criteria in 14.04 or, if growth
impairment, as described under the criteria in 100.00ff.

B. Linear scleroderma, with one of the following:
1. Fixed valgus or varus deformities of both hands or both feet; or
2. Marked destruction or marked atrophy of an extremity; or
3. Facial disfigurement from hypoplasia of the mandible, maxilla, or
zygoma resulting in an impairment as described under the criteria in
112.00ff; or
4. Seizure disorder, as described under the criteria in 111.00ff.
114.05 Polymyositis or dermatomyositis. Documented as described in
14.00B4 and 114.00B, and:
A. As described under the criteria in 14.05.

B. With one of the following:
1. Multiple joint contractures; or
2. Diffuse cutaneous calcification with formation of an exoskeleton;
or
3. Systemic vasculitis as described under the criteria in 14.03.
114.06 Undifferentiated connective tissue disorder. As described
under the criteria in 114.02 or 114.04.
114.07 Congenital immune deficiency disease.
A. Hypogammaglobulinemia or dysgammaglobulinemia, with:
1. Documented, recurrent severe infections occurring 3 or more times
within a 5-month period; or
2. An associated disorder such as growth retardation, chronic lung
disease, collagen disorder or tumor. Evaluate according to the
appropriate body system listing.

B. Thymic dysplastic syndromes (such as Swiss, diGeorge).
114.08 Human immunodeficiency virus (HIV) infection. With
documentation as described in 114.00D3 and one of the following:
A. Bacterial infections:
1. Mycobacterial infection (e.g., caused by M. avium-intracellulare,
M. kansasii, or M. tuberculosis) at a site other than the lungs, skin,
or cervical or hilar lymph nodes; or pulmonary tuberculosis resistant to
treatment; or
2. Nocardiosis; or
3. Salmonella bacteremia, recurrent non-typhoid.
4. Syphilis or neurosyphilis--evaluate sequelae under the criteria
for the affected body system (e.g., 102.00 Special Senses and Speech,
104.00 Cardiovascular System, 111.00 Neurological); or
5. In a child less than 13 years of age, multiple or recurrent
pyogenic bacterial infection(s) of the following types: sepsis,
pneumonia, meningitis, bone or joint infection, or abscess of an
internal organ or body cavity (excluding otitis media or superficial
skin or mucosal abscesses) occurring 2 or more times in 2 years; or
6. Other multiple or recurrent bacterial infection(s), including
pelvic inflammatory disease, requiring hospitalization or intravenous
antibiotic treatment 3 or more times in 1 year.

[[Page 460]]

3. Coccidioidomycosis, at a site other than the lungs or lymph
nodes; or
4. Cryptococcosis, at a site other than the lungs (e.g.,
cryptococcal meningitis); or
5. Histoplasmosis, at a site other than the lungs or lymph nodes; or
6. Mucormycosis.

D. Viral infections:
1. Cytomegalovirus disease (documented as described in 114.00D4b) at
a site other than the liver, spleen, or lymph nodes; or
2. Herpes simplex virus causing:
a. Mucocutaneous infection (e.g., oral, genital, perianal) lasting
for 1 month or longer; or
b. Infection at a site other than the skin or mucous membranes
(e.g., bronchitis, pneumonitis, esophagitis, or encephalitis); or
c. Disseminated infection; or
3. Herpes zoster, either disseminated or with multidermatomal
eruptions that are resistant to treatment; or
4. Progressive multifocal leukoencephalopathy; or
5. Hepatitis, as described under the criteria of 105.05.

E. Malignant neoplasms:
1. Carcinoma of the cervix, invasive, FIGO stage II and beyond; or
2. Karposi's sarcoma with:
a. Extensive oral lesions; or
b. Involvement of the gastrointestinal tract, lungs, or other
visceral organs; or
c. Involvement of the skin or mucous membranes as described under
the criteria of 114.08F; or
3. Lymphoma (e.g., primary lymphoma of the brain, Burkitt's
lymphoma, immunoblastic sarcoma, other Non-Hodgkin's lymphoma, Hodgkin's
disease); or
4. Squamous cell carcinoma of the anus.

F. Conditions of the skin or mucous membranes (other than described
in B2, D2, or D3 above) with extensive fungating or ulcerating lesions
not responding to treatment (e.g., dermatological conditions such as
eczema or psoriasis, vulvovaginal or other mucosal candida, condyloma
caused by human papillomavirus, genital ulcerative disease), or evaluate
under the criteria in 8.00ff.

H. Neurological manifestations of HIV infection (e.g., HIV
encephalopathy, peripheral neuropathy), as described under the criteria
in 111.00ff, or resulting in one or more of the following:
1. Loss of previously acquired, or marked delay in achieving,
developmental milestones or intellectual ability (including the sudden
acquisition of a new learning disability); or
2. Impaired brain growth (acquired microcephaly or brain atrophy--
see 114.00D5); or
3. Progressive motor dysfunction affecting gait and station or fine
and gross motor skills.

I. Growth disturbance, with:
1. An involuntary weight loss (or failure to gain weight at an
appropriate rate for age) resulting in a fall of 15 percentiles from
established growth curve (on standard growth charts) that persists for 2
months or longer; or
2. An involuntary weight loss (or failure to gain weight at an
appropriate rate for age) resulting in a fall to below the third
percentile from established growth curve (on standard growth charts)
that persists for 2 months or longer; or
3. Involuntary weight loss greater than 10 percent of baseline that
persists for 2 months or longer; or
4. Growth impairment as described under the criteria in 100.00ff.

J. Diarrhea, lasting for 1 month or longer, resistant to treatment,
and requiring intravenous hydration, intravenous alimentation, or tube
feeding.

K. Cardiomyopathy, as described under the criteria in 104.00ff or
11.04.

L. Lymphoid interstitial pneumonia/pulmonary lymphoid hyperplasia
(LIP/PLH complex), with respiratory symptoms that significantly
interfere with age-appropriate activities, and that cannot be controlled
by prescribed treatment.

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M. Nephropathy, as described under the criteria in 106.00.

N. One or more of the following infections (other than described in
A-M, above), resistant to treatment or requiring hospitalization or
intravenous treatment 3 or more times in 1 year (or evaluate sequelae
under the criteria for the affected body system):
1. Sepsis;
2. Meningitis; or
3. Pneumonia; or
4. Septic arthritis; or
5. Endocarditis; or
6. Radiographically documented sinusitis.

O. Any other manifestation(s) of HIV infection (including any listed
in 114.08A-N, but without the requisite findings, e.g., oral candidiasis
not meeting the criteria in 114.08F, diarrhea not meeting the criteria
in 114.08J, or any other manifestation(s), e.g., oral hairy leukoplakia,
hepatomegaly), resulting in one of the following:
1. For children from birth to attainment of age 1, at least one of
the criteria in paragraphs A-E of 112.12; or
2. For children age 1 to attainment of age 3, at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or
3. For children age 3 to attainment of age 18, at least two of the
appropriate age-group criteria in paragraph B2 of 112.02.

[50 FR 35066, Aug. 28, 1985]

Editorial Note: For Federal Register citations affecting appendix 1
to subpart P of part 404, see the List of CFR Sections Affected in the
Finding Aids section of this volume.
Pt. 404, Subpt. P, App. 2

Appendix 2 to Subpart P--Medical-Vocational Guidelines

Sec.
200.00 Introduction.
201.00 Maximum sustained work capability limited to sedentary work as a
result of severe medically determinable impairment(s).
202.00 Maximum sustained work capability limited to light work as a
result of severe medically determinable impairment(s).
203.00 Maximum sustained work capability limited to medium work as a
result of severe medically determinable impair- ment(s).
204.00 Maximum sustained work capability limited to heavy work (or very
heavy work) as a result of severe medically determinable
impairment(s).

200.00 Introduction. (a) The following rules reflect the major
functional and vocational patterns which are encountered in cases which
cannot be evaluated on medical considerations alone, where an individual
with a severe medically determinable physical or mental impairment(s) is
not engaging in substantial gainful activity and the individual's
impairment(s) prevents the performance of his or her vocationally
relevant past work. They also reflect the analysis of the various
vocational factors (i.e., age, education, and work experience) in
combination with the individual's residual functional capacity (used to
determine his or her maximum sustained work capability for sedentary,
light, medium, heavy, or very heavy work) in evaluating the individual's
ability to engage in substantial gainful activity in other than his or
her vocationally relevant past work. Where the findings of fact made
with respect to a particular individual's vocational factors and
residual functional capacity coincide with all of the criteria of a
particular rule, the rule directs a conclusion as to whether the
individual is or is not disabled. However, each of these findings of
fact is subject to rebuttal and the individual may present evidence to
refute such findings. Where any one of the findings of fact does not
coincide with the corresponding criterion of a rule, the rule does not
apply in that particular case and, accordingly, does not direct a
conclusion of disabled or not disabled. In any instance where a rule
does not apply, full consideration must be given to all of the relevant
facts of the case in accordance with the definitions and discussions of
each factor in the appropriate sections of the regulations.
(b) The existence of jobs in the national economy is reflected in
the ``Decisions'' shown in the rules; i.e., in promulgating the rules,
administrative notice has been taken of the numbers of unskilled jobs
that exist throughout the national economy at the various functional
levels (sedentary, light, medium, heavy, and very heavy) as supported by
the ``Dictionary of Occupational Titles'' and the ``Occupational Outlook
Handbook,'' published by the Department of Labor; the ``County Business
Patterns'' and ``Census Surveys'' published by the Bureau of the Census;
and occupational surveys of light and sedentary jobs prepared for the
Social Security Administration by various State employment agencies.
Thus, when all factors coincide with the criteria of a rule, the
existence of such jobs is established. However, the existence of such
jobs for individuals whose remaining functional capacity or other
factors do not coincide with the criteria of a rule must be further
considered in terms of what kinds of jobs or types of work may be either
additionally indicated or precluded.
(c) In the application of the rules, the individual's residual
functional capacity (i.e., the maximum degree to which the individual
retains the capacity for sustained performance of the physical-mental
requirements of jobs), age, education, and work experience

[[Page 462]]

must first be determined. When assessing the person's residual
functional capacity, we consider his or her symptoms (such as pain),
signs, and laboratory findings together with other evidence we obtain.
(d) The correct disability decision (i.e., on the issue of ability
to engage in substantial gainful activity) is found by then locating the
individual's specific vocational profile. If an individual's specific
profile is not listed within this appendix 2, a conclusion of disabled
or not disabled is not directed. Thus, for example, an individual's
ability to engage in substantial gainful work where his or her residual
functional capacity falls between the ranges of work indicated in the
rules (e.g., the individual who can perform more than light but less
than medium work), is decided on the basis of the principles and
definitions in the regulations, giving consideration to the rules for
specific case situations in this appendix 2. These rules represent
various combinations of exertional capabilities, age, education and work
experience and also provide an overall structure for evaluation of those
cases in which the judgments as to each factor do not coincide with
those of any specific rule. Thus, when the necessary judgments have been
made as to each factor and it is found that no specific rule applies,
the rules still provide guidance for decisionmaking, such as in cases
involving combinations of impairments. For example, if strength
limitations resulting from an individual's impairment(s) considered with
the judgments made as to the individual's age, education and work
experience correspond to (or closely approximate) the factors of a
particular rule, the adjudicator then has a frame of reference for
considering the jobs or types of work precluded by other, nonexertional
impairments in terms of numbers of jobs remaining for a particular
individual.
(e) Since the rules are predicated on an individual's having an
impairment which manifests itself by limitations in meeting the strength
requirements of jobs, they may not be fully applicable where the nature
of an individual's impairment does not result in such limitations, e.g.,
certain mental, sensory, or skin impairments. In addition, some
impairments may result solely in postural and manipulative limitations
or environmental restrictions. Environmental restrictions are those
restrictions which result in inability to tolerate some physical
feature(s) of work settings that occur in certain industries or types of
work, e.g., an inability to tolerate dust or fumes.
(1) In the evaluation of disability where the individual has solely
a nonexertional type of impairment, determination as to whether
disability exists shall be based on the principles in the appropriate
sections of the regulations, giving consideration to the rules for
specific case situations in this appendix 2. The rules do not direct
factual conclusions of disabled or not disabled for individuals with
solely nonexertional types of impairments.
(2) However, where an individual has an impairment or combination of
impairments resulting in both strength limitations and nonexertional
limitations, the rules in this subpart are considered in determining
first whether a finding of disabled may be possible based on the
strength limitations alone and, if not, the rule(s) reflecting the
individual's maximum residual strength capabilities, age, education, and
work experience provide a framework for consideration of how much the
individual's work capability is further diminished in terms of any types
of jobs that would be contraindicated by the nonexertional limitations.
Also, in these combinations of nonexertional and exertional limitations
which cannot be wholly determined under the rules in this appendix 2,
full consideration must be given to all of the relevant facts in the
case in accordance with the definitions and discussions of each factor
in the appropriate sections of the regulations, which will provide
insight into the adjudicative weight to be accorded each factor.
201.00 Maximum sustained work capability limited to sedentary work
as a result of severe medically determinable impairment(s). (a) Most
sedentary occupations fall within the skilled, semi-skilled,
professional, administrative, technical, clerical, and benchwork
classifications. Approximately 200 separate unskilled sedentary
occupations can be identified, each representing numerous jobs in the
national economy. Approximately 85 percent of these jobs are in the
machine trades and benchwork occupational categories. These jobs
(unskilled sedentary occupations) may be performed after a short
demonstration or within 30 days.
(b) These unskilled sedentary occupations are standard within the
industries in which they exist. While sedentary work represents a
significantly restricted range of work, this range in itself is not so
prohibitively restricted as to negate work capability for substantial
gainful activity.
(c) Vocational adjustment to sedentary work may be expected where
the individual has special skills or experience relevant to sedentary
work or where age and basic educational competences provide sufficient
occupational mobility to adapt to the major segment of unskilled
sedentary work. Inability to engage in substantial gainful activity
would be indicated where an individual who is restricted to sedentary
work because of a severe medically determinable impairment lacks special
skills or experience relevant to sedentary work, lacks educational
qualifications relevant to most sedentary work (e.g.,

[[Page 463]]

has a limited education or less) and the individual's age, though not
necessarily advanced, is a factor which significantly limits vocational
adaptability.
(d) The adversity of functional restrictions to sedentary work at
advanced age (55 and over) for individuals with no relevant past work or
who can no longer perform vocationally relevant past work and have no
transferable skills, warrants a finding of disabled in the the absence
of the rare situation where the individual has recently completed
education which provides a basis for direct entry into skilled sedentary
work. Advanced age and a history of unskilled work or no work experience
would ordinarily offset any vocational advantages that might accrue by
reason of any remote past education, whether it is more or less than
limited education.
(e) The presence of acquired skills that are readily transferable to
a significant range of skilled work within an individual's residual
functional capacity would ordinarily warrant a finding of ability to
engage in substantial gainful activity regardless of the adversity of
age, or whether the individual's formal education is commensurate with
his or her demonstrated skill level. The acquisition of work skills
demonstrates the ability to perform work at the level of complexity
demonstrated by the skill level attained regardless of the individual's
formal educational attainments.
(f) In order to find transferability of skills to skilled sedentary
work for individuals who are of advanced age (55 and over), there must
be very little, if any, vocational adjustment required in terms of
tools, work processes, work settings, or the industry.
(g) Individuals approaching advanced age (age 50-54) may be
significantly limited in vocational adaptability if they are restricted
to sedentary work. When such individuals have no past work experience or
can no longer perform vocationally relevant past work and have no
transferable skills, a finding of disabled ordinarily obtains. However,
recently completed education which provides for direct entry into
sedentary work will preclude such a finding. For this age group, even a
high school education or more (ordinarily completed in the remote past)
would have little impact for effecting a vocational adjustment unless
relevant work experience reflects use of such education.
(h) The term younger individual is used to denote an individual age
18 through 49. For those within this group who are age 45-49, age is a
less positive factor than for those who are age 18-44. Accordingly, for
such individuals; (1) who are restricted to sedentary work, (2) who are
unskilled or have no transferable skills, (3) who have no relevant past
work or who can no longer perform vocationally relevant past work, and
(4) who are either illiterate or unable to communicate in the English
language, a finding of disabled is warranted. On the other hand, age is
a more positive factor for those who are under age 45 and is usually not
a significant factor in limiting such an individual's ability to make a
vocational adjustment, even an adjustment to unskilled sedentary work,
and even where the individual is illiterate or unable to communicate in
English. However, a finding of disabled is not precluded for those
individuals under age 45 who do not meet all of the criteria of a
specific rule and who do not have the ability to perform a full range of
sedentary work. The following examples are illustrative: Example 1: An
individual under age 45 with a high school education can no longer do
past work and is restricted to unskilled sedentary jobs because of a
severe medically determinable cardiovascular impairment (which does not
meet or equal the listings in appendix 1). A permanent injury of the
right hand limits the individual to sedentary jobs which do not require
bilateral manual dexterity. None of the rules in appendix 2 are
applicable to this particular set of facts, because this individual
cannot perform the full range of work defined as sedentary. Since the
inability to perform jobs requiring bilateral manual dexterity
significantly compromises the only range of work for which the
individual is otherwise qualified (i.e., sedentary), a finding of
disabled would be appropriate. Example 2: An illiterate 41 year old
individual with mild mental retardation (IQ of 78) is restricted to
unskilled sedentary work and cannot perform vocationally relevant past
work, which had consisted of unskilled agricultural field work; his or
her particular characteristics do not specifically meet any of the rules
in appendix 2, because this individual cannot perform the full range of
work defined as sedentary. In light of the adverse factors which further
narrow the range of sedentary work for which this individual is
qualified, a finding of disabled is appropriate.
(i) While illiteracy or the inability to communicate in English may
significantly limit an individual's vocational scope, the primary work
functions in the bulk of unskilled work relate to working with things
(rather than with data or people) and in these work functions at the
unskilled level, literacy or ability to communicate in English has the
least significance. Similarly the lack of relevant work experience would
have little significance since the bulk of unskilled jobs require no
qualifying work experience. Thus, the functional capability for a full
range of sedentary work represents sufficient numbers of jobs to
indicate substantial vocational scope for those individuals age 18-44
even if they are illiterate or unable to communicate in English.

[[Page 464]]

Table No. 1--Residual Functional Capacity: Maximum Sustained Work Capability Limited to Sedentary Work as a
Result of Severe Medically Determinable Impairment(s)
----------------------------------------------------------------------------------------------------------------
Previous work
Rule Age Education experience Decision
----------------------------------------------------------------------------------------------------------------
201.01................ Advanced age......... Limited or less..... Unskilled or none... Disabled.
201.02................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
not transferable\1\.
201.03................ ......do............. ......do............ Skilled or Not disabled.
semiskilled--skills
transferable\1\.
201.04................ ......do............. High school graduate Unskilled or none... Disabled.
or more--does not
provide for direct
entry into skilled
work\2\.
201.05................ ......do............. High school graduate ......do............ Not disabled.
or more--provides
for direct entry
into skilled
work\2\.
201.06................ ......do............. High school graduate Skilled or Disabled.
or more--does not semiskilled--skills
provide for direct not transferable\1\.
entry into skilled
work\2\.
201.07................ ......do............. ......do............ Skilled or Not disabled.
semiskilled--skills
transferable\1\.
201.08................ ......do............. High school graduate Skilled or Do.
or more--provides semiskilled--skills
for direct entry not transferable\1\.
into skilled
work\2\.
201.09................ Closely approaching Limited or less..... Unskilled or none... Disabled.
advanced age.
201.10................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
not transferable.
201.11................ ......do............. ......do............ Skilled or Not disabled.
semiskilled--skills
transferable.
201.12................ ......do............. High school graduate Unskilled or none... Disabled.
or more--does not
provide for direct
entry into skilled
work\3\.
201.13................ ......do............. High school graduate ......do............ Not disabled.
or more--provides
for direct entry
into skilled
work\3\.
201.14................ ......do............. High school graduate Skilled or Disabled.
or more--does not semiskilled--skills
provide for direct not transferable.
entry into skilled
work\3\.
201.15................ ......do............. ......do............ Skilled or Not disabled.
semiskilled--skills
transferable.
201.16................ ......do............. High school graduate Skilled or Do.
or more--provides semiskilled--skills
for direct entry not transferable.
into skilled
work\3\.
201.17................ Younger individual Illiterate or unable Unskilled or none... Disabled.
age 45-49. to communicate in
English.
201.18................ ......do............. Limited or less--at ......do............ Not disabled.
least literate and
able to communicate
in English.
201.19................ ......do............. Limited or less..... Skilled or Do.
semiskilled--skills
not transferable.
201.20................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
201.21................ ......do............. High school graduate Skilled or Do.
or more. semiskilled--skills
not transferable.
201.22................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
201.23................ Younger individual Illiterate or unable Unskilled or none... Do.\4\
age 18-44. to communicate in
English.
201.24................ ......do............. Limited or less--at ......do............ Do.\4\
least literate and
able to communicate
in English.
201.25................ ......do............. Limited or less..... Skilled or Do.\4\
semiskilled--skills
not transferable.
201.26................ ......do............. ......do............ Skilled or Do.\4\
semiskilled--skills
transferable.
201.27................ ......do............. High school graduate Unskilled or none... Do.\4\
or more.
201.28................ ......do............. ......do............ Skilled or Do.\4\
semiskilled--skills
not transferable.

[[Page 465]]

201.29................ ......do............. ......do............ Skilled or Do.\4\
semiskilled--skills
transferable.
----------------------------------------------------------------------------------------------------------------
\1\See 201.00(f).
\2\See 201.00(d).
\3\See 201.00(g).
\4\See 201.00(h).

202.00 Maximum sustained work capability limited to light work as a
result of severe medically determinable impairment(s). (a) The
functional capacity to perform a full range of light work includes the
functional capacity to perform sedentary as well as light work.
approximately 1,600 separate sedentary and light unskilled occupations
can be identified in eight broad occupational categories, each
occupation representing numerous jobs in the national economy. These
jobs can be performed after a short demonstration or within 30 days, and
do not require special skills or experience.
(b) The functional capacity to perform a wide or full range of light
work represents substantial work capability compatible with making a
work adjustment to substantial numbers of unskilled jobs and, thus,
generally provides sufficient occupational mobility even for severely
impaired individuals who are not of advanced age and have sufficient
educational competences for unskilled work.
(c) However, for individuals of advanced age who can no longer
perform vocationally relevant past work and who have a history of
unskilled work experience, or who have only skills that are not readily
transferable to a significant range of semi-skilled or skilled work that
is within the individual's functional capacity, or who have no work
experience, the limitations in vocational adaptability represented by
functional restriction to light work warrant a finding of disabled.
Ordinarily, even a high school education or more which was completed in
the remote past will have little positive impact on effecting a
vocational adjustment unless relevant work experience reflects use of
such education.
(d) Where the same factors in paragraph (c) of this section
regarding education and work experience are present, but where age,
though not advanced, is a factor which significantly limits vocational
adaptability (i.e., closely approaching advanced age, 50-54) and an
individual's vocational scope is further significantly limited by
illiteracy or inability to communicate in English, a finding of disabled
is warranted.
(e) The presence of acquired skills that are readily transferable to
a significant range of semi-skilled or skilled work within an
individual's residual functional capacity would ordinarily warrant a
finding of not disabled regardless of the adversity of age, or whether
the individual's formal education is commensurate with his or her
demonstrated skill level. The acquisition of work skills demonstrates
the ability to perform work at the level of complexity demonstrated by
the skill level attained regardless of the individual's formal
educational attainments.
(f) For a finding of transferability of skills to light work for
individuals of advanced age who are closely approaching retirement age
(age 60-64), there must be very little, if any, vocational adjustment
required in terms of tools, work processes, work settings, or the
industry.
(g) While illiteracy or the inability to communicate in English may
significantly limit an individual's vocational scope, the primary work
functions in the bulk of unskilled work relate to working with things
(rather than with data or people) and in these work functions at the
unskilled level, literacy or ability to communicate in English has the
least significance. Similarly, the lack of relevant work experience
would have little significance since the bulk of unskilled jobs require
no qualifying work experience. The capability for light work, which
includes the ability to do sedentary work, represents the capability for
substantial numbers of such jobs. This, in turn, represents substantial
vocational scope for younger individuals (age 18-49) even if illiterate
or unable to communicate in English.

[[Page 466]]

Table No. 2--Residual Functional Capacity: Maximum Sustained Work Capability Limited to Light Work as a Result
of Severe Medically Determinable Impairment(s)
----------------------------------------------------------------------------------------------------------------
Previous work
Rule Age Education experience Decision
----------------------------------------------------------------------------------------------------------------
202.01................ Advanced age......... Limited or less..... Unskilled or none... Disabled.
202.02................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
not transferable.
202.03................ ......do............. ......do............ Skilled or Not disabled.
semiskilled--skills
transferable\1\.
202.04................ ......do............. High school graduate Unskilled or none... Disabled.
or more--does not
provide for direct
entry into skilled
work\2\.
202.05................ ......do............. High school graduate ......do............ Not disabled.
or more--provides
for direct entry
into skilled
work\2\.
202.06................ ......do............. High school graduate Skilled or Disabled.
or more--does not semiskilled--skills
provide for direct not transferable.
entry into skilled
work\2\.
202.07................ ......do............. ......do............ Skilled or Not disabled.
semiskilled--skills
transferable\2\.
202.08................ ......do............. High school graduate Skilled or Do.
or more--provides semiskilled--skills
for direct entry not transferable.
into skilled
work\2\.
202.09................ Closely approaching Illiterate or unable Unskilled or none... Disabled.
advanced age. to communicate in
English.
202.10................ ......do............. Limited or less--at ......do............ Not disabled.
least literate and
able to communicate
in English.
202.11................ ......do............. Limited or less..... Skilled or Do.
semiskilled--skills
not transferable.
202.12................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
202.13................ ......do............. High school graduate Unskilled or none... Do.
or more.
202.14................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
not transferable.
202.15................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
202.16................ Younger individual... Illiterate or unable Unskilled or none... Do.
to communicate in
English.
202.17................ ......do............. Limited or less--at ......do............ Do.
least literate and
able to communicate
in English.
202.18................ ......do............. Limited or less..... Skilled or Do.
semiskilled--skills
not transferable.
202.19................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
202.20................ ......do............. High school graduate Unskilled or none... Do.
or more.
202.21................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
not transferable.
202.22................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
----------------------------------------------------------------------------------------------------------------
\1\See 202.00(f).
\2\See 202.00(c).

203.00 Maximum sustained work capability limited to medium work as
a result of severe medically determinable impair- ment(s). (a) The
functional capacity to perform medium work includes the functional
capacity to perform sedentary, light, and medium work. Approximately
2,500 separate sedentary, light, and medium occupations can be
identified, each occupation representing numerous jobs in the national
economy which do not require skills or previous experience and which can
be performed after a short demonstration or within 30 days.
(b) The functional capacity to perform medium work represents such
substantial work capability at even the unskilled level that a finding
of disabled is ordinarily not warranted in cases where a severely
impaired individual retains the functional capacity to perform medium
work. Even the adversity of advanced age (55 or over) and a work history
of unskilled work may be offset by the substantial work capability
represented by the functional capacity to perform medium work. However,
an individual with a marginal education and long work experience (i.e.,
35 years or more) limited to the performance of arduous unskilled labor,
who is not working and is no longer able to perform this labor because
of a severe impairment(s),

[[Page 467]]

may still be found disabled even though the individual is able to do
medium work.
(c) However, the absence of any relevant work experience becomes a
more significant adversity for individuals of advanced age (55 and
over). Accordingly, this factor, in combination with a limited education
or less, militates against making a vocational adjustment to even this
substantial range of work and a finding of disabled is appropriate.
Further, for individuals closely approaching retirement age (60-64) with
a work history of unskilled work and with marginal education or less, a
finding of disabled is appropriate.

Table No. 3--Residual Functional Capacity: Maximum Sustained Work Capability Limited to Medium Work as a Result
of Severe Medically Determinable Impairment(s)
----------------------------------------------------------------------------------------------------------------
Previous work
Rule Age Education experience Decision
----------------------------------------------------------------------------------------------------------------
203.01................ Closely approaching Marginal or none.... Unskilled or none... Disabled.
retirement age.
203.02................ ......do............. Limited or less..... None................ Do.
203.03................ ......do............. Limited............. Unskilled........... Not disabled.
203.04................ ......do............. Limited or less..... Skilled or Do.
semiskilled--skills
not transferable.
203.05................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
203.06................ ......do............. High school graduate Unskilled or none... Do.
or more.
203.07................ ......do............. High school graduate Skilled or Do.
or more--does not semiskilled--skills
provide for direct not transferable.
entry into skilled
work.
203.08................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
203.09................ ......do............. High school graduate Skilled or Do.
or more--provides semiskilled--skills
for direct entry not transferable.
into skilled work.
203.10................ Advanced age......... Limited or less..... None................ Disabled.
203.11................ ......do............. ......do............ Unskilled........... Not disabled.
203.12................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
not transferable.
203.13................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
203.14................ ......do............. High school graduate Unskilled or none... Do.
or more.
203.15................ ......do............. High school graduate Skilled or Do.
or more--does not semiskilled--skills
provide for direct not transferable.
entry into skilled
work.
203.16................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
203.17................ ......do............. High school graduate Skilled or Do.
or more--provides semiskilled--skills
for direct entry not transferable.
into skilled work.
203.18................ Closely approaching Limited or less..... Unskilled or none... Do.
advanced age.
203.19................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
not transferable.
203.20................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
203.21................ ......do............. High school graduate Unskilled or none... Do.
or more.
203.22................ ......do............. High school graduate Skilled or Do.
or more--does not semiskilled--skills
provide for direct not transferable.
entry into skilled
work.
203.23................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
203.24................ ......do............. High school graduate Skilled or Do.
or more--provides semiskilled--skills
for direct entry not transferable.
into skilled work.
203.25................ Younger individual... Limited or less..... Unskilled or none... Do.
203.26................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
not transferable.
203.27................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.
203.28................ ......do............. High school graduate Unskilled or none... Do.
or more.
203.29................ ......do............. High school graduate Skilled or Do.
or more--does not semiskilled--skills
provide for direct not transferable.
entry into skilled
work.
203.30................ ......do............. ......do............ Skilled or Do.
semiskilled--skills
transferable.

[[Page 468]]

203.31................ ......do............. High school graduate Skilled or Do.
or more--provides semiskilled--skills
for direct entry not transferable.
into skilled work.
----------------------------------------------------------------------------------------------------------------

204.00 Maximum sustained work capability limited to heavy work (or
very heavy work) as a result of severe medically determinable
impairment(s). The residual functional capacity to perform heavy work or
very heavy work includes the functional capability for work at the
lesser functional levels as well, and represents substantial work
capability for jobs in the national economy at all skill and physical
demand levels. Individuals who retain the functional capacity to perform
heavy work (or very heavy work) ordinarily will not have a severe
impairment or will be able to do their past work--either of which would
have already provided a basis for a decision of ``not disabled''.
Environmental restrictions ordinarily would not significantly affect the
range of work existing in the national economy for individuals with the
physical capability for heavy work (or very heavy work). Thus an
impairment which does not preclude heavy work (or very heavy work) would
not ordinarily be the primary reason for unemployment, and generally is
sufficient for a finding of not disabled, even though age, education,
and skill level of prior work experience may be considered adverse.

[45 FR 55584, Aug. 20, 1980, as amended at 56 FR 57944, Nov. 14, 1991]}}}