[Title 20 CFR P]
[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]
[From the U.S. Government Printing Office]


20EMPLOYEES' BENEFITS21996-04-011996-04-01falseDetermining Disability and BlindnessPSubpart PEMPLOYEES' BENEFITSSOCIAL SECURITY ADMINISTRATIONFEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- )
Subpart P--Determining Disability and Blindness


Sec. 404.1501  Scope of subpart.

    In order for you to become entitled to any benefits based upon 
disability or blindness or to have a period of disability established, 
you must be disabled or blind as defined in title II of the Social 
Security Act. This subpart explains how we determine whether you are 
disabled or blind. We discuss a period of disability in subpart D of 
this part. We have organized the rules in the following way.
    (a) We define general terms, then discuss who makes our disability 
determinations and state that disability determinations made under other 
programs are not binding on our determinations.
    (b) We explain the term disability and note some of the major 
factors that are considered in determining whether you are disabled in 
Secs. 404.1505 through 404.1510.
    (c) Sections 404.1512 through 404.1518 contain our rules on 
evidence. We explain your responsibilities for submitting evidence of 
your impairment, state what we consider to be acceptable sources of 
medical evidence, and describe what information should be included in 
medical reports.
    (d) Our general rules on evaluating disability if you are filing a 
new application are stated in Secs. 404.1520 through 404.1523. We 
describe the steps that we go through and the order in which they are 
considered.
    (e) Our rules on medical considerations are found in Secs. 404.1525 
through 404.1530. We explain in these rules--

[[Page 310]]

    (1) The purpose of the Listing of Impairments found in appendix 1 of 
this subpart and how to use it;
    (2) What we mean by the term medical equivalence and how we 
determine medical equivalence;
    (3) The effect of a conclusion by your physician that you are 
disabled;
    (4) What we mean by symptoms, signs, and laboratory findings;
    (5) How we evaluate pain and other symptoms; and
    (6) The effect on your benefits if you fail to follow treatment that 
is expected to restore your ability to work, and how we apply the rule.
    (f) In Secs. 404.1545 through 404.1546 we explain what we mean by 
the term residual functional capacity, state when an assessment of 
residual functional capacity is required, and who may make it.
    (g) Our rules on vocational considerations are found in 
Secs. 404.1560 through 404.1569a. We explain when vocational factors 
must be considered along with the medical evidence, discuss the role of 
residual functional capacity in evaluating your ability to work, discuss 
the vocational factors of age, education, and work experience, describe 
what we mean by work which exists in the national economy, discuss the 
amount of exertion and the type of skill required for work, describe and 
tell how to use the Medical-Vocational Guidelines in appendix 2 of this 
subpart, and explain when, for purposes of applying the guidelines in 
appendix 2, we consider the limitations or restrictions imposed by your 
impairment(s) and related symptoms to be exertional, nonexertional, or a 
combination of both.
    (h) Our rules on substantial gainful activity are found in 
Secs. 404.1571 through 404.1574. These explain what we mean by 
substantial gainful activity and how we evaluate your work activity.
    (i) In Secs. 404.1577, 404.1578, and 404.1579, we explain the 
special rules covering disability for widows, widowers, and surviving 
divorced spouses for monthly benefits payable for months prior to 
January 1991, and in Secs. 404.1581 through 404.1587 we discuss 
disability due to blindness.
    (j) Our rules on when disability continues and stops are contained 
in Sec. 404.1579 and Secs. 404.1588 through 404.1598. We explain what 
your responsibilities are in telling us of any events that may cause a 
change in your disability status, when you may have a trial work period, 
and when we will review to see if you are still disabled. We also 
explain how we consider the issue of medical improvement (and the 
exceptions to medical improvement) in deciding whether you are still 
disabled.

[45 FR 55584, Aug. 20, 1980, as amended at 50 FR 50126, Dec. 6, 1985; 56 
FR 57941, Nov. 14, 1991; 57 FR 30120, July 8, 1992]



Sec. 404.1502  General definitions and terms for this subpart.

    As used in the subpart--
    Medical sources refers to treating sources, sources of record, and 
consultative examiners for us. See Sec. 404.1513.
    Secretary means the Secretary of Health and Human Services.
    Source of record means a hospital, clinic or other source that has 
provided you with medical treatment or evaluation, as well as a 
physician or psychologist who has treated or evaluated you but does not 
have or did not have an ongoing treatment relationship with you.
    State agency means that agency of a State which has been designated 
by the State to carry out the disability or blindness determination 
function.
    Treating source means your own physician or psychologist who has 
provided you with medical treatment or evaluation and who has or has had 
an ongoing treatment relationship with you. Generally, we will consider 
that you have an ongoing treatment relationship with a physician or 
psychologist when the medical evidence establishes that you see or have 
seen the physician or psychologist with a frequency consistent with 
accepted medical practice for the type of treatment and evaluation 
required for your medical condition(s). We may consider a physician or 
psychologist who has treated you only a few times or only after long 
intervals (e.g., twice a year) to be your treating source if the nature 
and frequency of the treatment is typical for your condition(s). We will 
not consider a physician or psychologist to be your treating physician 
if your relationship with the physician or psychologist is

[[Page 311]]

not based on your need for treatment, but solely on your need to obtain 
a report in support of your claim for disability. In such a case, we 
will consider the physician or psychologist to be a consulting physician 
or psychologist.
    We or us refers to either the Social Security Administration or the 
State agency making the disability or blindness determination.
    You refers to the person who has applied for benefits or for a 
period of disability or is receiving benefits based on disability or 
blindness.

[56 FR 36954, Aug. 1, 1991]

                             Determinations



Sec. 404.1503  Who makes disability and blindness determinations.

    (a) State agencies. State agencies make disability and blindness 
determinations for the Secretary for most persons living in the State. 
State agencies make these disability and blindness determinations under 
regulations containing performance standards and other administrative 
requirements relating to the disability and blindness determination 
function. States have the option of turning the function over to the 
Federal Government if they no longer want to make disability 
determinations. Also, the Secretary may take the function away from any 
State which has substantially failed to make disability and blindness 
determinations in accordance with these regulations. Subpart Q of this 
part contains the rules the States must follow in making disability and 
blindness determinations.
    (b) Social Security Administration. The Social Security 
Administration will make disability and blindness determinations for the 
Secretary for--
    (1) Any person living in a State which is not making for the 
Secretary any disability and blindness determinations or which is not 
making those determinations for the class of claimants to which that 
person belongs; and
    (2) Any person living outside the United States.
    (c) What determinations are authorized. The Secretary has authorized 
the State agencies and the Social Security Administration to make 
determinations about--
    (1) Whether you are disabled or blind;
    (2) The date your disability or blindness began; and
    (3) The date your disability or blindness stopped.
    (d) Review of State Agency determinations. On review of a State 
agency determination or redetermination of disability or blindness we 
may find that--
    (1) You are, or are not, disabled or blind, regardless of what the 
State agency found;
    (2) Your disability or blindness began earlier or later than the 
date found by the State agency; and
    (3) Your disability or blindness stopped earlier or later than the 
date found by the State agency.
    (e) Initial determinations for mental impairments. An initial 
determination by a State agency or the Social Security Administration 
that you are not disabled (or a Social Security Administration review of 
a State agency's initial determination), in any case where there is 
evidence which indicates the existence of a mental impairment, will be 
made only after every reasonable effort has been made to ensure that a 
qualified psychiatrist or psychologist has completed the medical portion 
of the case review and any applicable residual functional capacity 
assessment. (See Sec. 404.1616 for the qualifications we consider 
necessary for a psychologist to be a psychological consultant and 
Sec. 404.1617 for what we consider reasonable effort.) If the services 
of qualified psychiatrists or psychologists cannot be obtained because 
of impediments at the State level, the Secretary may contract directly 
for the services. In a case where there is evidence of mental and 
nonmental impairments and a qualified psychologist serves as a 
psychological consultant, the psychologist will evaluate only the mental 
impairment, and a physician will evaluate the nonmental impairment. The 
overall determination of impairment severity in combined mental and 
nonmental impairment cases will be made by a medical consultant and not 
a psychological consultant unless the mental impairment alone would 
justify a finding of disability.

[46 FR 29204, May 29, 1981, as amended at 52 FR 33926, Sept. 9, 1987]

[[Page 312]]



Sec. 404.1503a  Program integrity.

    We will not use in our program any individual or entity, except to 
provide existing medical evidence, who is currently excluded, suspended, 
or otherwise barred from participation in the Medicare or Medicaid 
programs, or any other Federal or Federally-assisted program; whose 
license to provide health care services is currently revoked or 
suspended by any State licensing authority pursuant to adequate due 
process procedures for reasons bearing on professional competence, 
professional conduct, or financial integrity; or who, until a final 
determination is made, has surrendered such a license while formal 
disciplinary proceedings involving professional conduct are pending. By 
individual or entity we mean a medical or psychological consultant, 
consultative examination provider, or diagnostic test facility. Also see 
Secs. 404.1519 and 404.1519g(b).

[56 FR 36954, Aug. 1, 1991]



Sec. 404.1504  Determinations by other organizations and agencies.

    A decision by any nongovernmental agency or any other governmental 
agency about whether you are disabled or blind is based on its rules and 
is not our decision about whether you are disabled or blind. We must 
make a disability or blindness determination based on social security 
law. Therefore, a determination made by another agency that you are 
disabled or blind is not binding on us.

                        Definition of Disability



Sec. 404.1505  Basic definition of disability.

    (a) The law defines disability as the inability to do any 
substantial gainful activity by reason of any medically determinable 
physical or mental impairment which can be expected to result in death 
or which has lasted or can be expected to last for a continuous period 
of not less than 12 months. To meet this definition, you must have a 
severe impairment, which makes you unable to do your previous work or 
any other substantial gainful activity which exists in the national 
economy. To determine whether you are able to do any other work, we 
consider your residual functional capacity and your age, education, and 
work experience. We will use this definition of disability if you are 
applying for a period of disability, or disability insurance benefits as 
a disabled worker, or child's insurance benefits based on disability 
before age 22 or, with respect to disability benefits payable for months 
after December 1990, as a widow, widower, or surviving divorced spouse.
    (b) There are different rules for determining disability for 
individuals who are statutorily blind. We discuss these in 
Secs. 404.1581 through 404.1587. There are also different rules for 
determining disability for widows, widowers, and surviving divorced 
spouses for monthly benefits for months prior to January 1991. We 
discuss these rules in Secs. 404.1577, 404.1578, and 404.1579.

[45 FR 55584, Aug. 20, 1980, as amended at 51 FR 10616, Mar. 28, 1986; 
57 FR 30120, July 8, 1992]



Sec. 404.1506  When we will not consider your impairment.

    (a) Permanent exclusion of felony-related impairment. In determining 
whether you are under a disability, we will not consider any physical or 
mental impairment, or any increase in severity (aggravation) of a 
preexisting impairment, which arises in connection with your commission 
of a felony after October 19, 1980, if you are subsequently convicted of 
this crime.Your subsequent conviction will invalidate any prior 
determination establishing disability if that determination was based 
upon any impairment, or aggravation, which we must exclude under this 
rule.
    (b) Limited use of impairment arising in prison. In determining 
whether you are under a disability for purposes of benefit payments, we 
will not consider any physical or mental impairment, or any increase in 
severity (aggravation) of a preexisting impairment, which arises in 
connection with your confinement in a jail, prison, or other penal 
institution or correctional facility for conviction of a felony 
committed after October 19, 1980. The exclusion of the impairment, or 
aggravation, applies in determining disability for benefits payable for 
any month during which you

[[Page 313]]

are confined. This rule does not preclude the establishment of a period 
of disability based upon the impairment or aggravation. You may become 
entitled to benefits upon release from prison provided that you apply 
and are under a disability at the time.
    (c) Felonious offenses. We will consider an offense a felony if--
    (1) It is a felony under applicable law; or
    (2) In a jurisdiction which does not classify any crime as a felony, 
it is an offense punishable by death or imprisonment for a term 
exceeding one year.
    (d) Confinement. In general, a jail, prison, or other penal 
institution or correctional facility is a facility which is under the 
control and jurisdiction of the agency in charge of the penal system or 
in which convicted criminals can be incarcerated. Confinement in such a 
facility continues as long as you are under a sentence of confinement 
and have not been released due to parole or pardon. You are considered 
confined even though you are temporarily or intermittently outside of 
the facility (e.g., on work release, attending school, or hospitalized).

[48 FR 5714, Feb. 8, 1983]



Sec. 404.1508  What is needed to show an impairment.

    If you are not doing substantial gainful activity, we always look 
first at your physical or mental impairment(s) to determine whether you 
are disabled or blind. Your impairment must result from anatomical, 
physiological, or psychological abnormalities which can be shown by 
medically acceptable clinical and laboratory diagnostic techniques. A 
physical or mental impairment must be established by medical evidence 
consisting of signs, symptoms, and laboratory findings, not only by your 
statement of symptoms (see Sec. 404.1527). (See Sec. 404.1528 for 
further information about what we mean by symptoms, signs, and 
laboratory findings.)

[45 FR 55584, Aug. 20, 1980, as amended at 56 FR 36954, Aug. 1, 1991]



Sec. 404.1509  How long the impairment must last.

    Unless your impairment is expected to result in death, it must have 
lasted or must be expected to last for a continuous period of at least 
12 months. We call this the duration requirement.



Sec. 404.1510  Meaning of substantial gainful activity.

    Substantial gainful activity means work that--
    (a) Involves doing significant and productive physical or mental 
duties; and
    (b) Is done (or intended) for pay or profit.
    (See Sec. 404.1572 for further details about what we mean by 
substantial gainful activity.)



Sec. 404.1511  Definition of a disabling impairment.

    (a) Disabled workers, persons disabled since childhood and, for 
months after December 1990, disabled widows, widowers, and surviving 
divorced spouses. If you are entitled to disability cash benefits as a 
disabled worker, or to child's insurance benefits, or, for monthly 
benefits payable after December 1990, to widow's, widower's, or 
surviving divorced spouse's monthly benefits, a disabling impairment is 
an impairment (or combination of impairments) which, of itself, is so 
severe that it meets or equals a set of criteria in the Listing of 
Impairments in appendix 1 of this subpart or which, when considered with 
your age, education, and work experience, would result in a finding that 
you are disabled under Sec. 404.1594. In determining whether you have a 
disabling impairment, earnings are not considered.
    (b) Disabled widows, widowers, and surviving divorced spouses, for 
monthly benefits for months prior to January 1991. If you have been 
entitled to disability benefits as a disabled widow, widower, or 
surviving divorced spouse and we must decide whether you had a disabling 
impairment for any time prior to January 1991, a disabling impairment is 
an impairment (or combination of impairments) which, of itself, was so 
severe that it met or equaled a set of criteria in the Listing of 
Impairments in appendix 1 of this subpart, or results in a finding that 
you were disabled under Sec. 404.1579. In determining

[[Page 314]]

whether you had a disabling impairment, earnings are not considered.

[57 FR 30120, July 8, 1992]

                                Evidence



Sec. 404.1512  Evidence of your impairment.

    (a) General. In general, you have to prove to us that you are blind 
or disabled. Therefore, you must bring to our attention everything that 
shows that you are blind or disabled. This means that you must furnish 
medical and other evidence that we can use to reach conclusions about 
your medical impairment(s) and, if material to the determination of 
whether you are blind or disabled, its effect on your ability to work on 
a sustained basis. We will consider only impairment(s) you say you have 
or about which we receive evidence.
    (b) What we mean by ``evidence.'' Evidence is anything you or anyone 
else submits to us or that we obtain that relates to your claim. This 
includes, but is not limited to:
    (1) Objective medical evidence, that is, medical signs and 
laboratory findings as defined in Sec. 404.1528 (b) and (c);
    (2) Other evidence from medical sources, such as medical history, 
opinions, and statements about treatment you have received;
    (3) Statements you or others make about your impairment(s), your 
restrictions, your daily activities, your efforts to work, or any other 
relevant statements you make to medical sources during the course of 
examination or treatment, or to us during interviews, on applications, 
in letters, and in testimony in our administrative proceedings;
    (4) Information from other sources, as described in 
Sec. 404.1513(e);
    (5) Decisions by any governmental or nongovernmental agency about 
whether you are disabled or blind; and
    (6) At the administrative law judge and Appeals Council levels, 
certain findings, other than the ultimate determination about whether 
you are disabled, made by State agency medical or psychological 
consultants and other program physicians or psychologists, and opinions 
expressed by medical advisors based on their review of the evidence in 
your case record. See Sec. 404.1527(f) (2) and (3).
    (c) Your responsibility. You must provide medical evidence showing 
that you have an impairment(s) and how severe it is during the time you 
say that you are disabled. If we ask you, you must also provide evidence 
about:
    (1) Your age;
    (2) Your education and training;
    (3) Your work experience;
    (4) Your daily activities both before and after the date you say 
that you became disabled;
    (5) Your efforts to work; and
    (6) Any other factors showing how your impairment(s) affects your 
ability to work. In Secs. 404.1560 through 404.1569, we discuss in more 
detail the evidence we need when we consider vocational factors.
    (d) Our responsibility. Before we make a determination that you are 
not disabled, we will develop your complete medical history for at least 
the 12 months preceding the month in which you file your application 
unless there is a reason to believe that development of an earlier 
period is necessary or unless you say that your disability began less 
than 12 months before you filed your application. We will make every 
reasonable effort to help you get medical reports from your own medical 
sources when you give us permission to request the reports.
    (1) ``Every reasonable effort'' means that we will make an initial 
request for evidence from your medical source and, at any time between 
10 and 20 calendar days after the initial request, if the evidence has 
not been received, we will make one followup request to obtain the 
medical evidence necessary to make a determination. The medical source 
will have a minimum of 10 calendar days from the date of our followup 
request to reply, unless our experience with that source indicates that 
a longer period is advisable in a particular case.
    (2) By ``complete medical history,'' we mean the records of your 
medical source(s) covering at least the 12 months preceding the month in 
which you file your application. If you say that your disability began 
less than 12 months before you filed your application, we will develop 
your complete

[[Page 315]]

medical history beginning with the month you say your disability began 
unless we have reason to believe your disability began earlier. If 
applicable, we will develop your complete medical history for the 12-
month period prior to (1) the month you were last insured for disability 
insurance benefits (see Sec. 404.130), (2) the month ending the 7-year 
period you may have to establish your disability and you are applying 
for widow's or widower's benefits based on disability (see 
Sec. 404.335(c)(1)), or (3) the month you attain age 22 and you are 
applying for child's benefits based on disability (see Sec. 404.350(e)).
    (e) Recontacting medical sources. When the evidence we receive from 
your treating physician or psychologist or other medical source is 
inadequate for us to determine whether you are disabled, we will need 
additional information to reach a determination or a decision. To obtain 
the information, we will take the following actions.
    (1) We will first recontact your treating physician or psychologist 
or other medical source to determine whether the additional information 
we need is readily available. We will seek additional evidence or 
clarification from your medical source when the report from your medical 
source contains a conflict or ambiguity that must be resolved, the 
report does not contain all the necessary information, or does not 
appear to be based on medically acceptable clinical and laboratory 
diagnostic techniques. We may do this by requesting copies of your 
medical source's records, a new report, or a more detailed report from 
your medical source, including your treating source, or by telephoning 
your medical source. In every instance where medical evidence is 
obtained over the telephone, the telephone report will be sent to the 
source for review, signature and return.
    (2) We may not seek additional evidence or clarification from a 
medical source when we know from past experience that the source either 
cannot or will not provide the necessary findings.
    (f) Need for consultative examination. If the information we need is 
not readily available from the records of your medical treatment source, 
or we are unable to seek clarification from your medical source, we will 
ask you to attend one or more consultative examinations at our expense. 
See Secs. 404.1517 through 404.1519t for the rules governing the 
consultative examination process. Generally, we will not request a 
consultative examination until we have made every reasonable effort to 
obtain evidence from your own medical sources. However, in some 
instances, such as when a source is known to be unable to provide 
certain tests or procedures or is known to be nonproductive or 
uncooperative, we may order a consultative examination while awaiting 
receipt of medical source evidence. We will not evaluate this evidence 
until we have made every reasonable effort to obtain evidence from your 
medical sources.

[56 FR 36954, Aug. 1, 1991]



Sec. 404.1513  Medical evidence of your impairment.

    (a) Acceptable sources. We need reports about your impairments from 
acceptable medical sources. Acceptable medical sources are--
    (1) Licensed physicians;
    (2) Licensed osteopaths;
    (3) Licensed or certified psychologists;
    (4) Licensed optometrists for the measurement of visual acuity and 
visual fields (we may need a report from a physician to determine other 
aspects of eye diseases); and
    (5) Persons authorized to send us a copy or summary of the medical 
records of a hospital, clinic, sanitorium, medical institution, or 
health care facility. Generally, the copy or summary should be certified 
as accurate by the custodian or by any authorized employee of the Social 
Security Administration, Veterans' Administration, or State agency. 
However, we will not return an uncertified copy or summary for 
certification unless there is some question about the document.
    (b) Medical reports. Medical reports should include--
    (1) Medical history;
    (2) Clinical findings (such as the results of physical or mental 
status examinations);
    (3) Laboratory findings (such as blood pressure, x-rays);

[[Page 316]]

    (4) Diagnosis (statement of disease or injury based on its signs and 
symptoms);
    (5) Treatment prescribed with response, and prognosis; and
    (6) A statement about what you can still do despite your 
impairment(s) based on the medical source's findings on the factors 
under paragraphs (b)(1) through (b)(5) of this section (except in 
statutory blindness claims). Although we will request a medical source 
statement about what you can still do despite your impairment(s), the 
lack of the medical source statement will not make the report 
incomplete. See Sec. 404.1527.
    (c) Statements about what you can still do. Statements about what 
you can still do (based on the medical source's findings on the factors 
under paragraphs (b)(1) through (b)(5) of this section) should describe, 
but are not limited to, the kinds of physical and mental capabilities 
listed below. See Secs. 404.1527 and 404.1545(c).
    (1) The medical source's opinion about your ability, despite your 
impairment(s), to do work-related activities such as sitting, standing, 
walking, lifting, carrying, handling objects, hearing, speaking, and 
traveling; and
    (2) In cases of mental impairment(s), the medical source's opinion 
about your ability to understand, to carry out and remember 
instructions, and to respond appropriately to supervision, coworkers, 
and work pressures in a work setting.
    (d) Completeness. The medical evidence, including the clinical and 
laboratory findings, must be complete and detailed enough to allow us to 
make a determination about whether you are disabled or blind. It must 
allow us to determine--
    (1) The nature and limiting effects of your impairment(s) for any 
period in question;
    (2) The probable duration of your impairment; and
    (3) Your residual functional capacity to do work-related physical 
and mental activities.
    (e) Information from other sources. Information from other sources 
may also help us to understand how your impairment affects your ability 
to work. Other sources include--
    (1) Public and private social welfare agencies;
    (2) Observations by non-medical sources; and
    (3) Other practitioners (for example, naturopaths, chiropractors, 
audiologists, etc.).

[45 FR 55584, Aug. 20, 1980, as amended at 56 FR 36955, Aug. 1, 1991]



Sec. 404.1514  When we will purchase existing evidence.

    We need specific medical evidence to determine whether you are 
disabled or blind. You are responsible for providing that evidence. 
However, we will pay physicians not employed by the Federal government 
and other non-Federal providers of medical services for the reasonable 
cost of providing us with existing medical evidence that we need and ask 
for after November 30, 1980.

[46 FR 45757, Sept. 15, 1981]



Sec. 404.1515  Where and how to submit evidence.

    You may give us evidence about your impairment at any of our offices 
or at the office of any State agency authorized to make disability 
determinations. You may also give evidence to one of our employees 
authorized to accept evidence at another place. For more information 
about this, see subpart H of this part.



Sec. 404.1516  If you fail to submit medical and other evidence.

    If you do not give us the medical and other evidence that we need 
and request, we will have to make a decision based on information 
available in your case. We will not excuse you from giving us evidence 
because you have religious or personal reasons against medical 
examinations, tests, or treatment.



Sec. 404.1517  Consultative examination at our expense.

    If your medical sources cannot or will not give us sufficient 
medical evidence about your impairment for us to determine whether you 
are disabled or blind, we may ask you to have one or more physical or 
mental examinations or tests. We will pay for these examinations. 
However, we will not pay for any medical examination arranged by you

[[Page 317]]

or your representative without our advance approval. If we arrange for 
the examination or test, we will give you reasonable notice of the date, 
time, and place the examination or test will be given, and the name of 
the person or facility who will do it. We will also give the examiner 
any necessary background information about your condition.

[56 FR 36956, Aug. 1, 1991]



Sec. 404.1518  If you do not appear at a consultative examination.

    (a) General. If you are applying for benefits and do not have a good 
reason for failing or refusing to take part in a consultative 
examination or test which we arrange for you to get information we need 
to determine your disability or blindness, we may find that you are not 
disabled or blind. If you are already receiving benefits and do not have 
a good reason for failing or refusing to take part in a consultative 
examination or test which we arranged for you, we may determine that 
your disability or blindness has stopped because of your failure or 
refusal. Therefore, if you have any reason why you cannot go for the 
scheduled appointment, you should tell us about this as soon as possible 
before the examination date. If you have a good reason, we will schedule 
another examination. We will consider your physical, mental, 
educational, and linguistic limitations (including any lack of facility 
with the English language) when determining if you have a good reason 
for failing to attend a consultative examination.
    (b) Examples of good reasons for failure to appear. Some examples of 
what we consider good reasons for not going to a scheduled examination 
include--
    (1) Illness on the date of the scheduled examination or test;
    (2) Not receiving timely notice of the scheduled examination or 
test, or receiving no notice at all;
    (3) Being furnished incorrect or incomplete information, or being 
given incorrect information about the physician involved or the time or 
place of the examination or test, or;
    (4) Having had death or serious illness occur in your immediate 
family.
    (c) Objections by your physician. If any of your treating physicians 
tell you that you should not take the examination or test, you should 
tell us at once. In many cases, we may be able to get the information we 
need in another way. Your physician may agree to another type of 
examination for the same purpose.

[45 FR 55584, Aug. 20, 1980, as amended at 59 FR 1635, Jan. 12, 1994]

Standards To Be Used in Determining When a Consultative Examination Will 
        Be Obtained in Connection With Disability Determinations



Sec. 404.1519  The consultative examination.

    A consultative examination is a physical or mental examination or 
test purchased for you at our request and expense from a treating 
physician or psychologist, another source of record, or an independent 
source, including a pediatrician when appropriate. The decision to 
purchase a consultative examination will be made on an individual case 
basis in accordance with the provisions of Secs. 404.1519a through 
404.1519f. Selection of the source for the examination will be 
consistent with the provisions of Sec. 404.1503a and Secs. 404.1519g 
through 404.1519j. The rules and procedures for requesting consultative 
examinations set forth in Secs. 404.1519a and 404.1519b are applicable 
at the reconsideration and hearing levels of review, as well as the 
initial level of determination.

[56 FR 36956, Aug. 1, 1991]



Sec. 404.1519a  When we will purchase a consultative examination and how we will use it.

    (a)(1) General. The decision to purchase a consultative examination 
for you will be made after we have given full consideration to whether 
the additional information needed (e.g., clinical findings, laboratory 
tests, diagnosis, and prognosis) is readily available from the records 
of your medical sources. See Sec. 404.1512 for the procedures we will 
follow to obtain evidence from your medical sources. Before purchasing a 
consultative examination, we will consider not only existing medical 
reports, but also the disability interview form containing your 
allegations

[[Page 318]]

as well as other pertinent evidence in your file.
    (2) When we purchase a consultative examination, we will use the 
report from the consultative examination to try to resolve a conflict or 
ambiguity if one exists. We will also use a consultative examination to 
secure needed medical evidence the file does not contain such as 
clinical findings, laboratory tests, a diagnosis or prognosis necessary 
for decision.
    (b) Situations requiring a consultative examination. A consultative 
examination may be purchased when the evidence as a whole, both medical 
and nonmedical, is not sufficient to support a decision on your claim. 
Other situations, including but not limited to the situations listed 
below, will normally require a consultative examination:
    (1) The additional evidence needed is not contained in the records 
of your medical sources;
    (2) The evidence that may have been available from your treating or 
other medical sources cannot be obtained for reasons beyond your 
control, such as death or noncooperation of a medical source;
    (3) Highly technical or specialized medical evidence that we need is 
not available from your treating or other medical sources;
    (4) A conflict, inconsistency, ambiguity or insufficiency in the 
evidence must be resolved, and we are unable to do so by recontacting 
your medical source; or
    (5) There is an indication of a change in your condition that is 
likely to affect your ability to work, but the current severity of your 
impairment is not established.

[56 FR 36956, Aug. 1, 1991]



Sec. 404.1519b  When we will not purchase a consultative examination.

    We will not purchase a consultative examination in situations 
including, but not limited to, the following situations:
    (a) In period of disability and disability insurance benefit claims, 
when you do not meet the insured status requirement in the calendar 
quarter you allege you became disabled or later and there is no 
possibility of establishing an earlier onset;
    (b) In claims for widow's or widower's benefits based on disability, 
when your alleged month of disability is after the end of the 7-year 
period specified in Sec. 404.335(c)(1) and there is no possibility of 
establishing an earlier onset date, or when the 7-year period expired in 
the past and there is no possibility of establishing an onset date prior 
to the date the 7-year period expired;
    (c) In disability insurance benefit claims, when your insured status 
expired in the past and there is no possibility of establishing an onset 
date prior to the date your insured status expired;
    (d) When any issues about your actual performance of substantial 
gainful activity or gainful activity have not been resolved;
    (e) In claims for child's benefits based on disability, when it is 
determined that your alleged disability did not begin before the month 
you attained age 22, and there is no possibility of establishing an 
onset date earlier than the month in which you attained age 22;
    (f) In claims for child's benefits based on disability that are 
filed concurrently with the insured individual's claim and entitlement 
cannot be established for the insured individual;
    (g) In claims for child's benefits based on disability where 
entitlement is precluded based on other nondisability factors.

[56 FR 36956, Aug. 1, 1991]

        Standards for the Type of Referral and for Report Content



Sec. 404.1519f  Type of purchased examinations.

    We will purchase only the specific examinations and tests we need to 
make a determination in your claim. For example, we will not authorize a 
comprehensive medical examination when the only evidence we need is a 
special test, such as an X-ray, blood studies, or an electrocardiogram.

[56 FR 36956, Aug. 1, 1991]



Sec. 404.1519g  Who we will select to perform a consultative examination.

    (a) We will purchase a consultative examination only from a 
qualified medical source. The medical source

[[Page 319]]

may be your own physician or psychologist, or another source. If you are 
a child, the medical source we choose may be a pediatrician. For a more 
complete list of medical sources, see Sec. 404.1513(a).
    (b) By ``qualified,'' we mean that the medical source must be 
currently licensed in the State and have the training and experience to 
perform the type of examination or test we will request; the medical 
source must not be barred from participation in our programs under the 
provisions of Sec. 404.1503a. The medical source must also have the 
equipment required to provide an adequate assessment and record of the 
existence and level of severity of your alleged impairments.
    (c) The physician or psychologist we choose may use support staff to 
help perform the consultative examination. Any such support staff (e.g., 
X-ray technician, nurse) must meet appropriate licensing or 
certification requirements of the State. See Sec. 404.1503a.

[56 FR 36957, Aug. 1, 1991]



Sec. 404.1519h  Your treating physician or psychologist.

    When in our judgment your treating physician or psychologist is 
qualified, equipped, and willing to perform the additional examination 
or tests for the fee schedule payment, and generally furnishes complete 
and timely reports, your treating physician or psychologist will be the 
preferred source to do the purchased examination. Even if only a 
supplemental test is required, your treating physician or psychologist 
is ordinarily the preferred source.

[56 FR 36957, Aug. 1, 1991]



Sec. 404.1519i  Other sources for consultative examinations.

    We will use a source other than your treating physician or 
psychologist for a purchased examination or test in situations 
including, but not limited to, the following situations:
    (a) Your treating physician or psychologist prefers not to perform 
such an examination or does not have the equipment to provide the 
specific data needed;
    (b) There are conflicts or inconsistencies in your file that cannot 
be resolved by going back to your treating physician or psychologist;
    (c) You prefer a source other than your treating physician or 
psychologist and have a good reason for your preference;
    (d) We know from prior experience that your treating physician or 
psychologist may not be a productive source, e.g., he or she has 
consistently failed to provide complete or timely reports.

[56 FR 36957, Aug. 1, 1991]



Sec. 404.1519j  Objections to the designated physician or psychologist.

    You or your representative may object to your being examined by a 
designated physician or psychologist. If there is a good reason for the 
objection, we will schedule the examination with another physician or 
psychologist. A good reason may be that the consultative examination 
physician or psychologist had previously represented an interest adverse 
to you. For example, the physician or psychologist may have represented 
your employer in a workers' compensation case or may have been involved 
in an insurance claim or legal action adverse to you. Other things we 
will consider include: the presence of a language barrier, the 
physician's or psychologist's office location (e.g., 2nd floor, no 
elevator), travel restrictions, and whether the physician or 
psychologist had examined you in connection with a previous disability 
determination or decision that was unfavorable to you. If your objection 
is because a physician or psychologist allegedly ``lacks objectivity'' 
in general, but not in relation to you personally, we will review the 
allegations. See Sec. 404.1519s. To avoid a delay in processing your 
claim, the consultative examination in your case will be changed to 
another physician or psychologist while a review is being conducted. We 
will handle any objection to use of the substitute physician or 
psychologist in the same manner. However, if we had previously conducted 
such a review and found that

[[Page 320]]

the reports of the consultative physician or psychologist in question 
conformed to our guidelines, we will not change your examination.

[56 FR 36957, Aug. 1, 1991]



Sec. 404.1519k  Purchase of medical examinations, laboratory tests, and other services.

    We may purchase medical examinations, including psychiatric and 
psychological examinations, X-rays and laboratory tests (including 
specialized tests such as pulmonary function studies, 
electrocardiograms, stress tests, etc.) from a licensed physician or 
psychologist, hospital or clinic.
    (a) The rate of payment to be used for purchasing medical or other 
services necessary to make determinations of disability may not exceed 
the highest rate paid by Federal or public agencies in the State for the 
same or similar types of service. See Secs. 404.1624 and 404.1626.
    (b) If a physician's bill or a request for payment for a physician's 
services includes a charge for a laboratory test for which payment may 
be made under this part, the amount payable with respect to the test 
shall be determined as follows:
    (1) If the bill or request for payment indicates that the test was 
personally performed or supervised by the physician who submitted the 
bill (or for whose services the request for payment was made) or by 
another physician with whom that physician shares his or her practice, 
the payment will be based on the physician's usual and customary charge 
for the test or the rates of payment which the State uses for purchasing 
such services, whichever is the lesser amount.
    (2) If the bill or request for payment indicates that the test was 
performed by an independent laboratory, the amount of reimbursement will 
not exceed the billed cost of the independent laboratory or the rate of 
payment which the State uses for purchasing such services, whichever is 
the lesser amount. A nominal payment may be made to the physician for 
collecting, handling and shipping a specimen to the laboratory if the 
physician bills for such a service. The total reimbursement may not 
exceed the rate of payment which the State uses for purchasing such 
services.
    (c) The State will assure that it can support the rate of payment it 
uses. The State shall also be responsible for monitoring and overseeing 
the rate of payment it uses to ensure compliance with paragraphs (a) and 
(b) of this section.

[56 FR 36957, Aug. 1, 1991]



Sec. 404.1519m  Diagnostic tests or procedures.

    We will request the results of any diagnostic tests or procedures 
that have been performed as part of a workup by your treating physician 
or psychologist or other medical source and will use the results to help 
us evaluate impairment severity or prognosis. However, we will not order 
diagnostic tests or procedures that involve significant risk to you, 
such as myelograms, arteriograms, or cardiac catheterizations for the 
evaluation of disability under the Social Security program. Also, a 
State agency medical consultant must approve the ordering of any 
diagnostic test or procedure when there is a chance it may involve 
significant risk. The responsibility for deciding whether to perform the 
examination rests with the consultative examining physician or 
psychologist.

[56 FR 36957, Aug. 1, 1991]



Sec. 404.1519n  Informing the examining physician or psychologist of examination scheduling, report content, and signature requirements.

    The physicians or psychologists who perform consultative 
examinations will have a good understanding of our disability programs 
and their evidentiary requirements. They will be made fully aware of 
their responsibilities and obligations regarding confidentiality as 
described in Sec. 401.105(e). We will fully inform consulting physicians 
or psychologists at the time we first contact them, and at subsequent 
appropriate intervals, of the following obligations:
    (a) In scheduling full consultative examinations, sufficient time 
should be allowed to permit the examining physician or psychologist to 
take a case history and perform the examination, including any needed 
tests. The following minimum scheduling intervals (i.e.,

[[Page 321]]

time set aside for the individual, not the actual duration of the 
consultative examination) should be used.
    (1) Comprehensive general medical examination--at least 30 minutes;
    (2) Comprehensive musculoskeletal or neurological examination--at 
least 20 minutes;
    (3) Comprehensive psychiatric examination--at least 40 minutes;
    (4) Psychological examination--at least 60 minutes (Additional time 
may be required depending on types of psychological tests administered); 
and
    (5) All others--at least 30 minutes, or in accordance with accepted 
medical practices.

We recognize that actual practice will dictate that some examinations 
may require longer scheduling intervals depending on the circumstances 
in a particular situation. We also recognize that these minimum 
intervals may have to be adjusted to allow for those claimants who do 
not attend their scheduled examination. The purpose of these minimum 
scheduling timeframes is to ensure that such examinations are complete 
and that sufficient time is made available to obtain the information 
needed to make an accurate determination in your case. State agencies 
will monitor the scheduling of examinations (through their normal 
consultative examination oversight activities) to ensure that any 
overscheduling is avoided, as overscheduling may lead to examinations 
that are not thorough.
    (b) Report content. The reported results of your medical history, 
examination, requested laboratory findings, discussions and conclusions 
must conform to accepted professional standards and practices in the 
medical field for a complete and competent examination. The facts in a 
particular case and the information and findings already reported in the 
medical and other evidence of record will dictate the extent of detail 
needed in the consultative examination report for that case. Thus, the 
detail and format for reporting the results of a purchased examination 
will vary depending upon the type of examination or testing requested. 
The reporting of information will differ from one type of examination to 
another when the requested examination relates to the performance of 
tests such as ventilatory function tests, treadmill exercise tests, or 
audiological tests. The medical report must be complete enough to help 
us determine the nature, severity, and duration of the impairment, and 
residual functional capacity. The report should reflect your statements 
of your symptoms, not simply the physician's or psychologist's 
statements or conclusions. The examining physician's or psychologist's 
report of the consultative examination should include the objective 
medical facts as well as observations and opinions.
    (c) Elements of a complete consultative examination. A complete 
consultative examination is one which involves all the elements of a 
standard examination in the applicable medical specialty. When the 
report of a complete consultative examination is involved, the report 
should include the following elements:
    (1) Your major or chief complaint(s);
    (2) A detailed description, within the area of specialty of the 
examination, of the history of your major complaint(s);
    (3) A description, and disposition, of pertinent ``positive'' and 
``negative'' detailed findings based on the history, examination and 
laboratory tests related to the major complaint(s), and any other 
abnormalities or lack thereof reported or found during examination or 
laboratory testing;
    (4) The results of laboratory and other tests (e.g., X-rays) 
performed according to the requirements stated in the Listing of 
Impairments (see appendix 1 of this subpart P);
    (5) The diagnosis and prognosis for your impairment(s);
    (6) A statement about what you can still do despite your 
impairment(s), unless the claim is based on statutory blindness. This 
statement should describe the opinion of the consultative physician or 
psychologist about your ability, despite your impairment(s), to do work-
related activities such as sitting, standing, walking, lifting, 
carrying, handling objects, hearing, speaking, and traveling; and, in 
cases of mental impairment(s), the opinion of the consultative physician 
or psychologist about your ability to understand, to carry out and 
remember instructions, and to respond appropriately to

[[Page 322]]

supervision, coworkers and work pressures in a work setting; and
    (7) In addition, the consultative physician or psychologist will 
consider, and provide some explanation or comment on, your major 
complaint(s) and any other abnormalities found during the history and 
examination or reported from the laboratory tests. The history, 
examination, evaluation of laboratory test results, and the conclusions 
will represent the information provided by the physician or psychologist 
who signs the report.
    (d) When a complete consultative examination is not required. When 
the evidence we need does not require a complete consultative 
examination (for example, we need only a specific laboratory test result 
to complete the record), we may not require a report containing all of 
the elements in paragraph (c).
    (e) Signature requirements. All consultative examination reports 
will be personally reviewed and signed by the physician or psychologist 
who actually performed the examination. This attests to the fact that 
the physician or psychologist doing the examination or testing is solely 
responsible for the report contents and for the conclusions, 
explanations or comments provided with respect to the history, 
examination and evaluation of laboratory test results. The signature of 
the examining physician or psychologist on a report annotated ``not 
proofed'' or ``dictated but not read'' is not acceptable. A rubber stamp 
signature of a physician or psychologist or the physician's or 
psychologist's signature entered by any other person is not acceptable.

[56 FR 36958, Aug. 1, 1991]



Sec. 404.1519o  When a properly signed consultative examination report has not been received.

    If a consultative examination report is received unsigned or 
improperly signed we will take the following action.
    (a) When we will make determinations and decisions without a 
properly signed report. We will make a determination or decision in the 
circumstances specified in paragraphs (a)(1) and (a)(2) of this section 
without waiting for a properly signed consultative examination report. 
After we have made the determination or decision, we will obtain a 
properly signed report and include it in the file unless the physician 
or psychologist who performed the original consultative examination has 
died.
    (1) Continuous period of disability allowance with an onset date as 
alleged or earlier than alleged; or
    (2) Continuance of disability.
    (b) When we will not make determinations and decisions without a 
properly signed report. We will not use an unsigned or improperly signed 
consultative examination report to make the determinations or decisions 
specified in paragraphs (b)(1), (b)(2), (b)(3), and (b)(4) of this 
section. When we need a properly signed consultative examination report 
to make these determinations or decisions, we must obtain such a report. 
If the signature of the physician or psychologist who performed the 
original examination cannot be obtained because the physician or 
psychologist is out of the country for an extended period of time, on an 
extended vacation, seriously ill, deceased, or for any other reason, the 
consultative examination will be rescheduled with another physician or 
psychologist.
    (1) Denial; or
    (2) Cessation; or
    (3) Allowance of a period of disability which has ended; or
    (4) Allowance with an onset date later than alleged.

[56 FR 36958, Aug. 1, 1991]



Sec. 404.1519p  Reviewing reports of consultative examinations.

    (a) We will review the report of the consultative examination to 
determine whether the specific information requested has been furnished. 
We will consider the following factors in reviewing the report:
    (1) Whether the report provides evidence which serves as an adequate 
basis for decisionmaking in terms of the impairment it assesses;
    (2) Whether the report is internally consistent; Whether all the 
diseases, impairments and complaints described in the history are 
adequately assessed and reported in the clinical findings; Whether the 
conclusions correlate the findings from your medical history,

[[Page 323]]

clinical examination and laboratory tests and explain all abnormalities;
    (3) Whether the report is consistent with the other information 
available to us within the specialty of the examination requested; 
Whether the report fails to mention an important or relevant complaint 
within that specialty that is noted in other evidence in the file (e.g., 
your blindness in one eye, amputations, pain, alcoholism, depression);
    (4) Whether this is an adequate report of examination as compared to 
standards set out in the course of a medical education; and
    (5) Whether the report is properly signed.
    (b) If the report is inadequate or incomplete, we will contact the 
examining consultative physician or psychologist, give an explanation of 
our evidentiary needs, and ask that the physician or psychologist 
furnish the missing information or prepare a revised report.
    (c) With your permission, or where the examination discloses new 
diagnostic information or test results that reveal potentially life-
threatening situations, we will refer the consultative examination 
report to your treating physician or psychologist. When we refer the 
consultative examination report to your treating physician or 
psychologist without your permission, we will notify you that we have 
done so.
    (d) We will perform ongoing special management studies on the 
quality of consultative examinations purchased from major medical 
sources and the appropriateness of the examinations authorized.
    (e) We will take steps to ensure that consultative examinations are 
scheduled only with medical sources who have access to the equipment 
required to provide an adequate assessment and record of the existence 
and level of severity of your alleged impairments.

[56 FR 36959, Aug. 1, 1991]



Sec. 404.1519q  Conflict of interest.

    All implications of possible conflict of interest between medical or 
psychological consultants and their medical or psychological practices 
will be avoided. Such consultants are not only those physicians and 
psychologists who work for us directly but are also those who do review 
and adjudication work in the State agencies. Physicians and 
psychologists who work for us directly as employees or under contract 
will not work concurrently for a State agency. Physicians and 
psychologists who do review work for us will not perform consultative 
examinations for us without our prior approval. In such situations, the 
physician or psychologist will disassociate himself or herself from 
further involvement in the case and will not participate in the 
evaluation, decision, or appeal actions. In addition, neither they, nor 
any member of their families, will acquire or maintain, either directly 
or indirectly, any financial interest in a medical partnership, 
corporation, or similar relationship in which consultative examinations 
are provided. Sometimes physicians and psychologists who do review work 
for us will have prior knowledge of a case; for example, when the 
claimant was a patient. Where this is so, the physician or psychologist 
will not participate in the review or determination of the case. This 
does not preclude the physician or psychologist from submitting medical 
evidence based on treatment or examination of the claimant.

[56 FR 36959, Aug. 1, 1991]

             Authorizing and Monitoring the Referral Process



Sec. 404.1519s  Authorizing and monitoring the consultative examination.

    (a) Day-to-day responsibility for the consultative examination 
process rests with the State agencies that make disability 
determinations for us.
    (b) The State agency will maintain a good working relationship with 
the medical community in order to recruit sufficient numbers of 
physicians and other providers of medical services to ensure ready 
availability of consultative examination providers.
    (c) Consistent with Federal and State laws, the State agency 
administrator will work to achieve appropriate rates of payment for 
purchased medical services.

[[Page 324]]

    (d) Each State agency will be responsible for comprehensive 
oversight management of its consultative examination program, with 
special emphasis on key providers.
    (e) A key consultative examination provider is a provider that meets 
at least one of the following conditions:
    (1) Any consultative examination provider with an estimated annual 
billing to the Social Security disability programs of at least $100,000; 
or
    (2) Any consultative examination provider with a practice of 
medicine, osteopathy, or psychology directed primarily towards 
evaluation examinations rather than the treatment of patients; or
    (3) Any consultative examination provider that does not meet the 
above criteria, but is one of the top five consultative examination 
providers in the State by dollar volume, as evidenced by prior year 
data.
    (f) State agencies have flexibility in managing their consultative 
examination programs, but at a minimum will provide:
    (1) An ongoing active recruitment program for consultative 
examination providers;
    (2) A process for orientation, training, and review of new 
consultative examination providers, with respect to SSA's program 
requirements involving consultative examination report content and not 
with respect to medical techniques;
    (3) Procedures for control of scheduling consultative examinations;
    (4) Procedures to ensure that close attention is given to specific 
evaluation issues involved in each case;
    (5) Procedures to ensure that only required examinations and tests 
are authorized in accordance with the standards set forth in this 
subpart;
    (6) Procedures for providing medical or supervisory approval for the 
authorization or purchase of consultative examinations and for 
additional tests or studies requested by consulting physicians and 
psychologists. This includes physician approval for the ordering of any 
diagnostic test or procedure where the question of significant risk to 
the claimant/beneficiary might be raised. See Sec. 404.1519m.
    (7) Procedures for the ongoing review of consultative examination 
results to ensure compliance with written guidelines;
    (8) Procedures to encourage active participation by physicians in 
the consultative examination oversight program;
    (9) Procedures for handling complaints;
    (10) Procedures for evaluating claimant reactions to key providers; 
and
    (11) A program of systematic, onsite reviews of key providers that 
will include annual onsite reviews of such providers when claimants are 
present for examinations. This provision does not contemplate that such 
reviews will involve participation in the actual examinations but, 
rather, offer an opportunity to talk with claimants at the provider's 
site before and after the examination and to review the provider's 
overall operation.
    (g) The State agencies will cooperate with us when we conduct 
monitoring activities in connection with their oversight management of 
their consultative examination programs.

[56 FR 36959, Aug. 1, 1991]

           Procedures To Monitor the Consultative Examination



Sec. 404.1519t  Consultative examination oversight.

    (a) We will ensure that referrals for consultative examinations and 
purchases of consultative examinations are made in accordance with our 
policies. We will also monitor both the referral processes and the 
product of the consultative examinations obtained. This monitoring may 
include reviews by independent medical specialists under direct contract 
with SSA.
    (b) Through our regional offices, we will undertake periodic 
comprehensive reviews of each State agency to evaluate each State's 
management of the consultative examination process. The review will 
involve visits to key providers, with State staff participating, 
including a program physician when the visit will deal with medical 
techniques or judgment, or factors that go to the core of medical 
professionalism.
    (c) We will also perform ongoing special management studies of the 
quality

[[Page 325]]

of consultative examinations purchased from key providers and other 
sources and the appropriateness of the examinations authorized.

[56 FR 36960, Aug. 1, 1991]

                        Evaluation of Disability



Sec. 404.1520  Evaluation of disability in general.

    (a) Steps in evaluating disability. We consider all evidence in your 
case record when we make a determination or decision whether you are 
disabled. When you file a claim for a period of disability and/or 
disability insurance benefits or for child's benefits based on 
disability, we use the following evaluation process. If you are doing 
substantial gainful activity, we will determine that you are not 
disabled. If you are not doing substantial gainful activity, we will 
first consider the effect of your physical or mental impairment; if you 
have more than one impairment, we will also consider the combined effect 
of your impairments. Your impairment(s) must be severe and meet the 
duration requirement before we can find you to be disabled. We follow a 
set order to determine whether you are disabled. We review any current 
work activity, the severity of your impairment(s), your residual 
functional capacity, your past work, and your age, education, and work 
experience. If we can find that you are disabled or not disabled at any 
point in the review, we do not review your claim further. Once you have 
been found entitled to disability benefits, we follow a somewhat 
different order of evaluation to determine whether your entitlement 
continues, as explained in Sec. 404.1594(f)(6).
    (b) If you are working. If you are working and the work you are 
doing is substantial gainful activity, we will find that you are not 
disabled regardless of your medical condition or your age, education, 
and work experience.
    (c) You must have a severe impairment. If you do not have any 
impairment or combination of impairments which significantly limits your 
physical or mental ability to do basic work activities, we will find 
that you do not have a severe impairment and are, therefore, not 
disabled. We will not consider your age, education, and work experience. 
However, it is possible for you to have a period of disability for a 
time in the past even though you do not now have a severe impairment.
    (d) When your impairment(s) meets or equals a listed impairment in 
appendix 1. If you have an impairment(s) which meets the duration 
requirement and is listed in appendix 1 or is equal to a listed 
impairment(s), we will find you disabled without considering your age, 
education, and work experience.
    (e) Your impairments(s) must prevent you from doing past relevant 
work. If we cannot make a decision based on your current work activity 
or on medical facts alone, and you have a severe impairment(s), we then 
review your residual functional capacity and the physical and mental 
demands of the work you have done in the past. If you can still do this 
kind of work, we will find that you are not disabled.
    (f) Your impairment(s) must prevent you from doing any other work. 
(1) If you cannot do any work you have done in the past because you have 
a severe impairment(s), we will consider your residual functional 
capacity and your age, education, and past work experience to see if you 
can do other work. If you cannot, we will find you disabled.
    (2) If you have only a marginal education, and long work experience 
(i.e., 35 years or more) where you only did arduous unskilled physical 
labor, and you can no longer do this kind of work, we use a different 
rule (see Sec. 404.1562).

[50 FR 8727, Mar. 5, 1985; 50 FR 19164, May 7, 1985, as amended at 56 FR 
36960, Aug. 1, 1991]



Sec. 404.1520a  Evaluation of mental impairments.

    (a) General. The steps outlined in Sec. 404.1520 apply to the 
evaluation of physical and mental impairments. In addition, in 
evaluating the severity of mental impairments for adults (persons age 18 
and over) and in persons under age 18 when Part A of the Listing of 
Impairments is used, a special procedure must be followed by us at each 
level of adminstrative review. Following this procedure will assist us 
in:
    (1) Identifying additional evidence necessary for the determination 
of impairment severity;

[[Page 326]]

    (2) Considering and evaluating aspects of the mental disorder(s) 
relevant to your ability to work; and
    (3) Organizing and presenting the findings in a clear, concise, and 
consistent manner.
    (b) Use of the procedure to record pertinent findings and rate the 
degree of functional loss. (1) This procedure requires us to record the 
pertinent signs, symptoms, findings, functional limitations, and effects 
of treatment contained in your case record. This will assist us in 
determining if a mental impairment(s) exists. Whether or not a mental 
impairment(s) exists is decided in the same way the question of a 
physical impairment is decided, i.e., the evidence must be carefully 
reviewed and conclusions supported by it. The mental status examination 
and psychiatric history will ordinarily provide the needed information. 
(See Sec. 404.1508 for further information about what is needed to show 
an impairment.)
    (2) If we determine that a mental impairment(s) exists, this 
procedure then requires us to indicate whether certain medical findings 
which have been found especially relevant to the ability to work are 
present or absent.
    (3) The procedure then requires us to rate the degree of functional 
loss resulting from the impairment(s). Four areas of function considered 
by us as essential to work have been identified, and the degree of 
functional loss in those areas must be rated on a scale that ranges from 
no limitation to a level of severity which is incompatible with the 
ability to perform those work-related functions. For the first two areas 
(activities of daily living and social functioning), the rating of 
limitation must be done based upon the following five point scale: none, 
slight, moderate, marked, and extreme. For the third area 
(concentration, persistence, or pace) the following five point scale 
must be used: never, seldom, often, frequent, and constant. For the 
fourth area (deterioration or decompensation in work or work-like 
settings), the following four point scale must be used: never, once or 
twice, repeated (three or more), and continual. The last two points for 
each of these scales represent a degree of limitation which is 
incompatible with the ability to perform the work-related function.
    (c) Use of the procedure to evaluate mental impairments. Following 
the rating of the degree of functional loss resulting from the 
impairment, we must then determine the severity of the mental 
impairment(s).
    (1) If the four areas considered by us as essential to work have 
been rated to indicate a degree of limitation as none or slight in the 
first and second areas, never or seldom in the third area, and never in 
the fourth area, we can generally conclude that the impairment is not 
severe, unless the evidence otherwise indicates there is significant 
limitation of your mental ability to do basic work activities (see 
Sec. 404.1521).
    (2) If your mental impairment(s) is severe, we must then determine 
if it meets or equals a listed mental disorder. This is done by 
comparing our prior conclusions based on this procedure (i.e., the 
presence of certain medical findings considered by us as especially 
relevant to your ability to work and our rating of functional loss 
resulting from the mental impairment(s)) against the paragraph A and B 
criteria of the appropriate listed mental disorder(s). If we determine 
that paragraph C criteria will be used in lieu of paragraph B criteria 
(see listings 12.03 and 12.06), we will, by following this procedure, 
indicate on the document whether the evidence is sufficient to establish 
the presence or absence of the criteria. (See paragraph (d) of this 
section).
    (3) If you have a severe impairment(s), but the impairment(s) 
neither meets nor equals the listings, we must then do a residual 
functional capacity assessment.
    (4) At all adjudicative levels we must, in each case, incorporate 
the pertinent findings and conclusions based on this procedure in our 
decision rationale. Our rationale must show the significant history, 
including examination, laboratory findings, and functional limitations 
that we considered in reaching conclusions about the severity of the 
mental impairment(s).
    (d) Preparation of the document. A standard document outlining the 
steps of this procedure must be completed by

[[Page 327]]

us in each case at the initial, reconsideration, administrative law 
judge hearing, and Appeals Council levels (when the Appeals Council 
issues a decision).
    (1) At the initial and reconsideration levels the standard document 
must be completed and signed by our medical consultant. At the 
administrative law judge hearing level, several options are available:
    (i) The administrative law judge may complete the document without 
the assistance of a medical advisor;
    (ii) The administrative law judge may call a medical advisor for 
assistance in preparing the document; or
    (iii) Where new evidence is received that is not merely cumulative 
of evidence already in your case file or where the issue of a mental 
impairment arises for the first time at the administrative law judge 
hearing level, the administrative law judge may decide to remand the 
case to the State agency for completion of the document and a new 
determination. Remand may also be made in situations where the services 
of a medical advisor are determined necessary but unavailable to the 
administrative law judge. In such circumstances, however, a remand may 
ordinarily be made only once.
    (2) For all cases involving mental disorders at the administrative 
law judge hearing or Appeals Council levels, the standard document will 
be appended to the decision.

(Approved by the Office of Management and Budget under control number 
0960-0413)

[50 FR 35065, Aug. 28, 1985, as amended at 55 FR 51229, Dec. 12, 1990; 
57 FR 30120, July 8, 1992]



Sec. 404.1521  What we mean by an impairment(s) that is not severe.

    (a) Non-severe impairment(s). An impairment or combination of 
impairments is not severe if it does not significantly limit your 
physical or mental ability to do basic work activities.
    (b) Basic work activities. When we talk about basic work activities, 
we mean the abilities and aptitudes necessary to do most jobs. Examples 
of these include--
    (1) Physical functions such as walking, standing, sitting, lifting, 
pushing, pulling, reaching, carrying, or handling;
    (2) Capacities for seeing, hearing, and speaking;
    (3) Understanding, carrying out, and remembering simple 
instructions;
    (4) Use of judgment;
    (5) Responding appropriately to supervision, co-workers and usual 
work situations; and
    (6) Dealing with changes in a routine work setting.

[50 FR 8728, Mar. 5, 1985]



Sec. 404.1522  When you have two or more unrelated impairments--initial claims.

    (a) Unrelated severe impairments. We cannot combine two or more 
unrelated severe impairments to meet the 12-month duration test. If you 
have a severe impairment(s) and then develop another unrelated severe 
impairment(s) but neither one is expected to last for 12 months, we 
cannot find you disabled, even though the two impairments in combination 
last for 12 months.
    (b) Concurrent impairments. If you have two or more concurrent 
impairments which, when considered in combination, are severe, we must 
also determine whether the combined effect of your impairments can be 
expected to continue to be severe for 12 months. If one or more of your 
impairments improves or is expected to improve within 12 months, so that 
the combined effect of your remaining impairments is no longer severe, 
we will find that you do not meet the 12-month duration test.

[50 FR 8728, Mar. 5, 1985]



Sec. 404.1523  Multiple impairments.

    In determining whether your physical or mental impairment or 
impairments are of a sufficient medical severity that such impairment or 
impairments could be the basis of eligibility under the law, we will 
consider the combined effect of all of your impairments without regard 
to whether any such impairment, if considered separately, would be of 
sufficient severity. If we do find a medically severe combination of 
impairments, the combined

[[Page 328]]

impact of the impairments will be considered throughout the disability 
determination process. If we do not find that you have a medically 
severe combination of impairments, we will determine that you are not 
disabled (see Sec. 404.1520).

[50 FR 8728, Mar. 5, 1985]

                         Medical Considerations



Sec. 404.1525  Listing of Impairments in Appendix 1.

    (a) Purpose of the Listing of Impairments. The Listing of 
Impairments describes, for each of the major body systems, impairments 
which are considered severe enough to prevent a person from doing any 
gainful activity. Most of the listed impairments are permanent or 
expected to result in death, or a specific statement of duration is 
made. For all others, the evidence must show that the impairment has 
lasted or is expected to last for a continuous period of at least 12 
months.
    (b) Adult and childhood diseases. The Listing of Impairments 
consists of two parts:
    (1) Part A contains medical criteria that apply to adult persons age 
18 and over. The medical criteria in part A may also be applied in 
evaluating impairments in persons under age 18 if the disease processes 
have a similar effect on adults and younger persons.
    (2) Part B contains additional medical criteria that apply only to 
the evaluation of impairments of persons under age 18. Certain criteria 
in part A do not give appropriate consideration to the particular 
effects of the disease processes in childhood; i.e., when the disease 
process is generally found only in children or when the disease process 
differs in its effect on children than on adults. Additional criteria 
are included in part B, and the impairment categories are, to the extent 
possible, numbered to maintain a relationship with their counterparts in 
part A. In evaluating disability for a person under age 18, part B will 
be used first. If the medical criteria in part B do not apply, then the 
medical criteria in part A will be used.
    (c) How to use the Listing of Impairments. Each section of the 
Listing of Impairments has a general introduction containing definitions 
of key concepts used in that section. Certain specific medical findings, 
some of which are required in establishing a diagnosis or in confirming 
the existence of an impairment for the purpose of this Listing, are also 
given in the narrative introduction. If the medical findings needed to 
support a diagnosis are not given in the introduction or elsewhere in 
the listing, the diagnosis must still be established on the basis of 
medically acceptable clinical and laboratory diagnostic techniques. 
Following the introduction in each section, the required level of 
severity of impairment is shown under ``Category of Impairments'' by one 
or more sets of medical findings. The medical findings consist of 
symptoms, signs, and laboratory findings.
    (d) Diagnosis of impairments. We will not consider your impairment 
to be one listed in appendix 1 solely because it has the diagnosis of a 
listed impairment. It must also have the findings shown in the Listing 
of that impairment.
    (e) Addiction to alcohol or drugs. If you have a condition diagnosed 
as addiction to alcohol or drugs, this will not, by itself, be a basis 
for determining whether you are, or are not, disabled. As with any other 
medical condition, we will decide whether you are disabled based on 
symptoms, signs, and laboratory findings.
    (f) Symptoms as criteria of listed impairment(s). Some listed 
impairment(s) include symptoms usually associated with those 
impairment(s) as criteria. Generally, when a symptom is one of the 
criteria in a listed impairment, it is only necessary that the symptom 
be present in combination with the other criteria. It is not necessary, 
unless the listing specifically states otherwise, to provide information 
about the intensity, persistence or limiting effects of the symptom as 
long as all other findings required by the specific listing are present.

[45 FR 55584, Aug. 20, 1980, as amended at 56 FR 57941, Nov. 14, 1991]



Sec. 404.1526  Medical equivalence.

    (a) How medical equivalence is determined. We will decide that your

[[Page 329]]

impairment(s) is medically equivalent to a listed impairment in appendix 
1 if the medical findings are at least equal in severity and duration to 
the listed findings. We will compare the symptoms, signs, and laboratory 
findings about your impairment(s), as shown in the medical evidence we 
have about your claim, with the medical criteria shown with the listed 
impairment. If your impairment is not listed, we will consider the 
listed impairment most like your impairment to decide whether your 
impairment is medically equal. If you have more than one impairment, and 
none of them meets or equals a listed impairment, we will review the 
symptoms, signs, and laboratory findings about your impairments to 
determine whether the combination of your impairments is medically equal 
to any listed impairment.
    (b) Medical equivalence must be based on medical findings. We will 
always base our decision about whether your impairment(s) is medically 
equal to a listed impairment on medical evidence only. Any medical 
findings in the evidence must be supported by medically acceptable 
clinical and laboratory diagnostic techniques. We will also consider the 
medical opinion given by one or more medical or psychological 
consultants designated by the Secretary in deciding medical equivalence. 
(See Sec. 404.1616.)
    (c) Who is a designated medical or psychological consultant. A 
medical or psychological consultant designated by the Secretary includes 
any medical or psychological consultant employed or engaged to make 
medical judgments by the Social Security Administration, the Railroad 
Retirement Board, or a State agency authorized to make disability 
determinations. A medical consultant must be a physician. A 
psychological consultant used in cases where there is evidence of a 
mental impairment must be a qualified psychologist. (See Sec. 404.1616 
for the qualifications we consider necessary for a psychologist to be a 
consultant.)

[45 FR 55584, Aug. 20, 1980, as amended at 52 FR 33926, Sept. 9, 1987]



Sec. 404.1527  Evaluating medical opinions about your impairment(s) or disability.

    (a) General. (1) You can only be found disabled if you are unable to 
do any substantial gainful activity by reason of any medically 
determinable physical or mental impairment which can be expected to 
result in death or which has lasted or can be expected to last for a 
continuous period of not less than 12 months. See Sec. 404.1505. Your 
impairment must result from anatomical, physiological, or psychological 
abnormalities which are demonstrable by medically acceptable clinical 
and laboratory diagnostic techniques. See Sec. 404.1508.
    (2) Evidence that you submit or that we obtain may contain medical 
opinions. Medical opinions are statements from physicians and 
psychologists or other acceptable medical sources that reflect judgments 
about the nature and severity of your impairment(s), including your 
symptoms, diagnosis and prognosis, what you can still do despite 
impairment(s), and your physical or mental restrictions.
    (b) How we consider medical opinions. In deciding whether you are 
disabled, we will always consider the medical opinions in your case 
record together with the rest of the relevant evidence we receive.
    (c) Making disability determinations. After we review all of the 
evidence relevant to your claim, including medical opinions, we make 
findings about what the evidence shows.
    (1) If all of the evidence we receive, including all medical 
opinion(s), is consistent, and there is sufficient evidence for us to 
decide whether you are disabled, we will make our determination or 
decision based on that evidence.
    (2) If any of the evidence in your case record, including any 
medical opinion(s), is inconsistent with other evidence or is internally 
inconsistent, we will weigh all of the evidence and see whether we can 
decide whether you are disabled based on the evidence we have.
    (3) If the evidence is consistent but we do not have sufficient 
evidence to decide whether you are disabled, or if after weighing the 
evidence we decide

[[Page 330]]

we cannot reach a conclusion about whether you are disabled, we will try 
to obtain additional evidence under the provisions of Secs. 404.1512 and 
404.1519 through 404.1519h. We will request additional existing records, 
recontact your treating sources or any other examining sources, ask you 
to undergo a consultative examination at our expense, or ask you or 
others for more information. We will consider any additional evidence we 
receive together with the evidence we already have.
    (4) When there are inconsistencies in the evidence that cannot be 
resolved, or when despite efforts to obtain additional evidence the 
evidence is not complete, we will make a determination or decision based 
on the evidence we have.
    (d) How we weigh medical opinions. Regardless of its source, we will 
evaluate every medical opinion we receive. Unless we give a treating 
source's opinion controlling weight under paragraph (d)(2) of this 
section, we consider all of the following factors in deciding the weight 
we give to any medical opinion.
    (1) Examining relationship. Generally, we give more weight to the 
opinion of a source who has examined you than to the opinion of a source 
who has not examined you.
    (2) Treatment relationship. Generally, we give more weight to 
opinions from your treating sources, since these sources are likely to 
be the medical professionals most able to provide a detailed, 
longitudinal picture of your medical impairment(s) and may bring a 
unique perspective to the medical evidence that cannot be obtained from 
the objective medical findings alone or from reports of individual 
examinations, such as consultative examinations or brief 
hospitalizations. If we find that a treating source's opinion on the 
issue(s) of the nature and severity of your impairment(s) is well-
supported by medically acceptable clinical and laboratory diagnostic 
techniques and is not inconsistent with the other substantial evidence 
in your case record, we will give it controlling weight. When we do not 
give the treating source's opinion controlling weight, we apply the 
factors listed below, as well as the factors in paragraphs (d) (3) 
through (5) of this section in determining the weight to give the 
opinion. We will always give good reasons in our notice of determination 
or decision for the weight we give your treating source's opinion.
    (i) Length of the treatment relationship and the frequency of 
examination. Generally, the longer a treating source has treated you and 
the more times you have been seen by a treating source, the more weight 
we will give to the source's medical opinion. When the treating source 
has seen you a number of times and long enough to have obtained a 
longitudinal picture of your impairment, we will give the source's 
opinion more weight than we would give it if it were from a nontreating 
source.
    (ii) Nature and extent of the treatment relationship. Generally, the 
more knowledge a treating source has about your impairment(s) the more 
weight we will give to the source's medical opinion. We will look at the 
treatment the source has provided and at the kinds and extent of 
examinations and testing the source has performed or ordered from 
specialists and independent laboratories. For example, if your 
ophthalmologist notices that you have complained of neck pain during 
your eye examinations, we will consider his or her opinion with respect 
to your neck pain, but we will give it less weight than that of another 
physician who has treated you for the neck pain. When the treating 
source has reasonable knowledge of your impairment(s), we will give the 
source's opinion more weight than we would give it if it were from a 
nontreating source.
    (3) Supportability. The more a medical source presents relevant 
evidence to support an opinion, particularly medical signs and 
laboratory findings, the more weight we will give that opinion. The 
better an explanation a source provides for an opinion, the more weight 
we will give that opinion. Furthermore, because nonexamining sources 
have no examining or treating relationship with you, the weight we will 
give their opinions will depend on the degree to which they provide 
supporting explanations for their opinions. We will evaluate the degree 
to which these opinions consider all of the pertinent evidence in your 
claim, including

[[Page 331]]

opinions of treating and other examining sources.
    (4) Consistency. Generally, the more consistent an opinion is with 
the record as a whole, the more weight we will give to that opinion.
    (5) Specialization. We generally give more weight to the opinion of 
a specialist about medical issues related to his or her area of 
specialty than to the opinion of a source who is not a specialist.
    (6) Other factors. When we consider how much weight to give to a 
medical opinion, we will also consider any factors you or others bring 
to our attention, or of which we are aware, which tend to support or 
contradict the opinion.
    (e) Medical source opinions on issues reserved to the Secretary.
    (1) Opinions that you are disabled. We are responsible for making 
the determination or decision about whether you meet the statutory 
definition of disability. In so doing, we review all of the medical 
findings and other evidence that support a medical source's statement 
that you are disabled. A statement by a medical source that you are 
``disabled'' or ``unable to work'' does not mean that we will determine 
that you are disabled.
    (2) Other opinions on issues reserved to the Secretary. We use 
medical sources, including your treating source, to provide evidence, 
including opinions, on the nature and severity of your impairment(s). 
Although we consider opinions from treating and examining sources on 
issues such as whether your impairment(s) meets or equals the 
requirements of any impairment(s) in the Listing of Impairments in 
appendix 1 of this subpart, your residual functional capacity (see 
Secs. 404.1545 and 404.1546), or the application of vocational factors, 
the final responsibility for deciding these issues is reserved to the 
Secretary. We will not give any special significance to the source of 
the opinion on these issues.
    (f) Opinions of nonexamining medical and psychological consultants 
and other nonexamining physicians and psychologists. We consider all 
evidence from nonexamining physicians and psychologists to be opinion 
evidence. When we consider the opinions of nonexamining sources on the 
nature and severity of your impairments, we apply the rules set forth in 
paragraphs (a) through (e) of this section. In addition, the following 
rules apply to State agency medical and psychological consultants, and 
to medical advisors we consult in connection with administrative law 
judge hearings and Appeals Council review.
    (1) At the initial and reconsideration steps in the administrative 
review process, except in disability hearings, State agency medical and 
psychological consultants are members of the teams that make the 
determinations of disability. A State agency medical or psychological 
consultant will consider the evidence in your case record and make 
findings of fact about the medical issues, including, but not limited 
to, the existence and severity of your impairment(s), the existence and 
severity of your symptoms, whether your impairment(s) meets or equals 
the requirements for any impairment listed in Appendix 1 to this 
subpart, and your residual functional capacity. These administrative 
findings of fact are based on the evidence in your case record but are 
not themselves evidence at these steps.
    (2) Administrative law judges are responsible for reviewing the 
evidence and making findings of fact and conclusions of law. 
Administrative law judges are not bound by any findings made by State 
agency medical or psychological consultants. However, these findings are 
considered at the hearing level. See Sec. 404.1512(b)(6). When 
administrative law judges consider these findings, they will evaluate 
them using the rules set forth in paragraphs (a) through (e) of this 
section. Also, administrative law judges may ask for and consider the 
opinions of medical advisors on the nature and severity of your 
impairment(s) and whether your impairment(s) equals the requirements of 
any listed impairment in appendix 1 to this subpart.
    (3) When the Appeals Council makes a decision, it will follow the 
same rules for considering opinion evidence as administrative law judges 
follow.

[56 FR 36960, Aug. 1, 1991]

[[Page 332]]



Sec. 404.1528  Symptoms, signs, and laboratory findings.

    Medical findings consist of symptoms, signs, and laboratory 
findings:
    (a) Symptoms are your own description of your physical or mental 
impairment. Your statements alone are not enough to establish that there 
is a physical or mental impairment.
    (b) Signs are anatomical, physiological, or psychological 
abnormalities which can be observed, apart from your statements 
(symptoms). Signs must be shown by medically acceptable clinical 
diagnostic techniques. Pyschiatric signs are medically demonstrable 
phenomena which indicate specific abnormalities of behavior, affect, 
thought, memory, orientation and contact with reality. They must also be 
shown by observable facts that can be medically described and evaluated.
    (c) Laboratory findings are anatomical, physiological, or 
psychological phenomena which can be shown by the use of medically 
acceptable laboratory diagnostic techniques. Some of these diagnostic 
techniques include chemical tests, electrophysiological studies 
(electrocardiogram, electroencephalogram, etc.), roentgenological 
studies (X-rays), and psychological tests.



Sec. 404.1529  How we evaluate symptoms, including pain.

    (a) General. In determining whether you are disabled, we consider 
all your symptoms, including pain, and the extent to which your symptoms 
can reasonably be accepted as consistent with the objective medical 
evidence and other evidence. By objective medical evidence, we mean 
medical signs and laboratory findings as defined in Sec. 404.1528 (b) 
and (c). By other evidence, we mean the kinds of evidence described in 
Secs. 404.1512(b) (2) through (6) and 404.1513(b) (1), (4), and (5) and 
(e). These include statements or reports from you, your treating or 
examining physician or psychologist, and others about your medical 
history, diagnosis, prescribed treatment, daily activities, efforts to 
work, and any other evidence showing how your impairment(s) and any 
related symptoms affect your ability to work. We will consider all of 
your statements about your symptoms, such as pain, and any description 
you, your physician, your psychologist, or other persons may provide 
about how the symptoms affect your activities of daily living and your 
ability to work. However, statements about your pain or other symptoms 
will not alone establish that you are disabled; there must be medical 
signs and laboratory findings which show that you have a medical 
impairment(s) which could reasonably be expected to produce the pain or 
other symptoms alleged and which, when considered with all of the other 
evidence (including statements about the intensity and persistence of 
your pain or other symptoms which may reasonably be accepted as 
consistent with the medical signs and laboratory findings), would lead 
to a conclusion that you are disabled. In evaluating the intensity and 
persistence of your symptoms, including pain, we will consider all of 
the available evidence, including your medical history, the medical 
signs and laboratory findings and statements about how your symptoms 
affect you. (Section 404.1527 explains how we consider opinions of your 
treating source and other medical opinions on the existence and severity 
of your symptoms, such as pain.) We will then determine the extent to 
which your alleged functional limitations and restrictions due to pain 
or other symptoms can reasonably be accepted as consistent with the 
medical signs and laboratory findings and other evidence to decide how 
your symptoms affect your ability to work.
    (b) Need for medically determinable impairment that could reasonably 
be expected to produce your symptoms, such as pain. Your symptoms, such 
as pain, fatigue, shortness of breath, weakness, or nervousness, will 
not be found to affect your ability to do basic work activities unless 
medical signs or laboratory findings show that a medically determinable 
impairment(s) is present. Medical signs and laboratory findings, 
established by medically acceptable clinical or laboratory diagnostic 
techniques, must show the existence of a medical impairment(s) which 
results from anatomical, physiological, or psychological abnormalities 
and which could reasonably be expected to produce the pain or other 
symptoms alleged. At the

[[Page 333]]

initial or reconsideration step in the administrative review process 
(except in disability hearings), a State agency medical or psychological 
consultant (or other medical or psychological consultant designated by 
the Secretary) directly participates in determining whether your 
medically determinable impairment(s) could reasonably be expected to 
produce your alleged symptoms. In the disability hearing process, a 
medical or psychological consultant may provide an advisory assessment 
to assist a disability hearing officer in determining whether your 
impairment(s) could reasonably be expected to produce your alleged 
symptoms. At the administrative law judge hearing or Appeals Council 
level, the administrative law judge or the Appeals Council may ask for 
and consider the opinion of a medical advisor concerning whether your 
impairment(s) could reasonably be expected to produce your alleged 
symptoms. The finding that your impairment(s) could reasonably be 
expected to produce your pain or other symptoms does not involve a 
determination as to the intensity, persistence, or functionally limiting 
effects of your symptoms. We will develop evidence regarding the 
possibility of a medically determinable mental impairment when we have 
information to suggest that such an impairment exists, and you allege 
pain or other symptoms but the medical signs and laboratory findings do 
not substantiate any physical impairment(s) capable of producing the 
pain or other symptoms.
    (c) Evaluating the intensity and persistence of your symptoms, such 
as pain, and determining the extent to which your symptoms limit your 
capacity for work--(1) General. When the medical signs or laboratory 
findings show that you have a medically determinable impairment(s) that 
could reasonably be expected to produce your symptoms, such as pain, we 
must then evaluate the intensity and persistence of your symptoms so 
that we can determine how your symptoms limit your capacity for work. In 
evaluating the intensity and persistence of your symptoms, we consider 
all of the available evidence, including your medical history, the 
medical signs and laboratory findings, and statements from you, your 
treating or examining physician or psychologist, or other persons about 
how your symptoms affect you. We also consider the medical opinions of 
your treating source and other medical opinions as explained in 
Sec. 404.1527. Paragraphs (c)(2) through (c)(4) of this section explain 
further how we evaluate the intensity and persistence of your symptoms 
and how we determine the extent to which your symptoms limit your 
capacity for work, when the medical signs or laboratory findings show 
that you have a medically determinable impairment(s) that could 
reasonably be expected to produce your symptoms, such as pain.
    (2) Consideration of objective medical evidence. Objective medical 
evidence is evidence obtained from the application of medically 
acceptable clinical and laboratory diagnostic techniques, such as 
evidence of reduced joint motion, muscle spasm, sensory deficit or motor 
disruption. Objective medical evidence of this type is a useful 
indicator to assist us in making reasonable conclusions about the 
intensity and persistence of your symptoms and the effect those 
symptoms, such as pain, may have on your ability to work. We must always 
attempt to obtain objective medical evidence and, when it is obtained, 
we will consider it in reaching a conclusion as to whether you are 
disabled. However, we will not reject your statements about the 
intensity and persistence of your pain or other symptoms or about the 
effect your symptoms have on your ability to work solely because the 
available objective medical evidence does not substantiate your 
statements.
    (3) Consideration of other evidence. Since symptoms sometimes 
suggest a greater severity of impairment than can be shown by objective 
medical evidence alone, we will carefully consider any other information 
you may submit about your symptoms. The information that you, your 
treating or examining physician or psychologist, or other persons 
provide about your pain or other symptoms (e.g., what may precipitate or 
aggravate your symptoms, what medications, treatments or other methods 
you use to alleviate them, and how the symptoms may affect your

[[Page 334]]

pattern of daily living) is also an important indicator of the intensity 
and persistence of your symptoms. Because symptoms, such as pain, are 
subjective and difficult to quantify, any symptom-related functional 
limitations and restrictions which you, your treating or examining 
physician or psychologist, or other persons report, which can reasonably 
be accepted as consistent with the objective medical evidence and other 
evidence, will be taken into account as explained in paragraph (c)(4) of 
this section in reaching a conclusion as to whether you are disabled. We 
will consider all of the evidence presented, including information about 
your prior work record, your statements about your symptoms, evidence 
submitted by your treating, examining or consulting physician or 
psychologist, and observations by our employees and other persons. 
Section 404.1527 explains in detail how we consider and weigh treating 
source and other medical opinions about the nature and severity of your 
impairment(s) and any related symptoms, such as pain. Factors relevant 
to your symptoms, such as pain, which we will consider include:
    (i) Your daily activities;
    (ii) The location, duration, frequency, and intensity of your pain 
or other symptoms;
    (iii) Precipitating and aggravating factors;
    (iv) The type, dosage, effectiveness, and side effects of any 
medication you take or have taken to alleviate your pain or other 
symptoms;
    (v) Treatment, other than medication, you receive or have received 
for relief of your pain or other symptoms;
    (vi) Any measures you use or have used to relieve your pain or other 
symptoms (e.g., lying flat on your back, standing for 15 to 20 minutes 
every hour, sleeping on a board, etc.); and
    (vii) Other factors concerning your functional limitations and 
restrictions due to pain or other symptoms.
    (4) How we determine the extent to which symptoms, such as pain, 
affect your capacity to perform basic work activities. In determining 
the extent to which your symptoms, such as pain, affect your capacity to 
perform basic work activities, we consider all of the available evidence 
described in paragraphs (c)(1) through (c)(3) of this section. We will 
consider your statements about the intensity, persistence, and limiting 
effects of your symptoms, and we will evaluate your statements in 
relation to the objective medical evidence and other evidence, in 
reaching a conclusion as to whether you are disabled. We will consider 
whether there are any inconsistencies in the evidence and the extent to 
which there are any conflicts between your statements and the rest of 
the evidence, including your medical history, the medical signs and 
laboratory findings, and statements by your treating or examining 
physician or psychologist or other persons about how your symptoms 
affect you. Your symptoms, including pain, will be determined to 
diminish your capacity for basic work activities to the extent that your 
alleged functional limitations and restrictions due to symptoms, such as 
pain, can reasonably be accepted as consistent with the objective 
medical evidence and other evidence.
    (d) Consideration of symptoms in the disability determination 
process. We follow a set order of steps to determine whether you are 
disabled. If you are not doing substantial gainful activity, we consider 
your symptoms, such as pain, to evaluate whether you have a severe 
physical or mental impairment(s), and at each of the remaining steps in 
the process. Sections 404.1520 and 404.1520a explain this process in 
detail. We also consider your symptoms, such as pain, at the appropriate 
steps in our review when we consider whether your disability continues. 
Sections 404.1579 and 404.1594 explain the procedure we follow in 
reviewing whether your disability continues.
    (1) Need to establish a severe medically determinable impairment(s). 
Your symptoms, such as pain, fatigue, shortness of breath, weakness, or 
nervousness, are considered in making a determination as to whether your 
impairment or combination of impairment(s) is severe. (See 
Sec. 404.1520(c).)
    (2) Decision whether the Listing of Impairments is met. Some listed 
impairment(s) include symptoms, such as pain, as criteria. Section 
404.1525(f)

[[Page 335]]

explains how we consider your symptoms when your symptoms are included 
as criteria for a listed impairment.
    (3) Decision whether the Listing of Impairments is equaled. If your 
impairment is not the same as a listed impairment, we must determine 
whether your impairment(s) is medically equivalent to a listed 
impairment. Section 404.1526 explains how we make this determination. 
Under Sec. 404.1526(b), we will consider equivalence based on medical 
evidence only. In considering whether your symptoms, signs, and 
laboratory findings are medically equal to the symptoms, signs, and 
laboratory findings of a listed impairment, we will look to see whether 
your symptoms, signs, and laboratory findings are at least equal in 
severity to the listed criteria. However, we will not substitute your 
allegations of pain or other symptoms for a missing or deficient sign or 
laboratory finding to raise the severity of your impairment(s) to that 
of a listed impairment. If the symptoms, signs, and laboratory findings 
of your impairment(s) are equivalent in severity to those of a listed 
impairment, we will find you disabled. If it does not, we will consider 
the impact of your symptoms on your residual functional capacity. (See 
paragraph (d)(4) of this section.)
    (4) Impact of symptoms (including pain) on residual functional 
capacity. If you have a medically determinable severe physical or mental 
impairment(s), but your impairment(s) does not meet or equal an 
impairment listed in Appendix 1 of this subpart, we will consider the 
impact of your impairment(s) and any related symptoms, including pain, 
on your residual functional capacity. (See Sec. 404.1545.)

[56 FR 57941, Nov. 14, 1991]



Sec. 404.1530  Need to follow prescribed treatment.

    (a) What treatment you must follow. In order to get benefits, you 
must follow treatment prescribed by your physician if this treatment can 
restore your ability to work.
    (b) When you do not follow prescribed treatment. If you do not 
follow the prescribed treatment without a good reason, we will not find 
you disabled or, if you are already receiving benefits, we will stop 
paying you benefits.
    (c) Acceptable reasons for failure to follow prescribed treatment. 
We will consider your physical, mental, educational, and linguistic 
limitations (including any lack of facility with the English language) 
when determining if you have an acceptable reason for failure to follow 
prescribed treatment. The following are examples of a good reason for 
not following treatment:
    (1) The specific medical treatment is contrary to the established 
teaching and tenets of your religion.
    (2) The prescribed treatment would be cataract surgery for one eye, 
when there is an impairment of the other eye resulting in a severe loss 
of vision and is not subject to improvement through treatment.
    (3) Surgery was previously performed with unsuccessful results and 
the same surgery is again being recommended for the same impairment.
    (4) The treatment because of its magnitude (e.g. open heart 
surgery), unusual nature (e.g., organ transplant), or other reason is 
very risky for you; or
    (5) The treatment involves amputation of an extremity, or a major 
part of an extremity.

[45 FR 55584, Aug. 20, 1980, as amended at 59 FR 1635, Jan. 12, 1994]



Sec. 404.1535  How we will determine whether your drug addiction or alcoholism is a contributing factor material to the determination of disability.

    (a) General. If we find that you are disabled and have medical 
evidence of your drug addiction or alcoholism, we must determine whether 
your drug addiction or alcoholism is a contributing factor material to 
the determination of disability.
    (b) Process we will follow when we have medical evidence of your 
drug addiction or alcoholism. (1) The key factor we will examine in 
determining whether drug addiction or alcoholism is a contributing 
factor material to the determination of disability is whether we would 
still find you disabled if you stopped using drugs or alcohol.
    (2) In making this determination, we will evaluate which of your 
current physical and mental limitations, upon

[[Page 336]]

which we based our current disability determination, would remain if you 
stopped using drugs or alcohol and then determine whether any or all of 
your remaining limitations would be disabling.
    (i) If we determine that your remaining limitations would not be 
disabling, we will find that your drug addiction or alcoholism is a 
contributing factor material to the determination of disability.
    (ii) If we determine that your remaining limitations are disabling, 
you are disabled independent of your drug addiction or alcoholism and we 
will find that your drug addiction or alcoholism is not a contributing 
factor material to the determination of disability.

[60 FR 8147, Feb. 10, 1995]



Sec. 404.1536  Treatment required for individuals whose drug addiction or alcoholism is a contributing factor material to the determination of disability.

    (a) If we determine that you are disabled and drug addiction or 
alcoholism is a contributing factor material to the determination of 
disability (as described in Sec. 404.1535), you must avail yourself of 
appropriate treatment for your drug addiction or alcoholism at an 
institution or facility approved by us when this treatment is available 
and make progress in your treatment. Generally, you are not expected to 
pay for this treatment. You will not be paid benefits for any month 
after the month we have notified you in writing that--
    (1) You did not comply with the terms, conditions and requirements 
of the treatment which has been made available to you; or
    (2) You did not avail yourself of the treatment after you had been 
notified that it is available to you.
    (b) If your benefits are suspended for failure to comply with 
treatment requirements, your benefits can be reinstated in accordance 
with the rules in Sec. 404.470.

[60 FR 8147, Feb. 10, 1995]



Sec. 404.1537  What we mean by appropriate treatment.

    By appropriate treatment, we mean treatment for drug addiction or 
alcoholism that serves the needs of the individual in the least 
restrictive setting possible consistent with your treatment plan. These 
settings range from outpatient counseling services through a variety of 
residential treatment settings including acute detoxification, short-
term intensive residential treatment, long-term therapeutic residential 
treatment, and long-term recovery houses. Appropriate treatment is 
determined with the involvement of a State licensed or certified 
addiction professional on the basis of a detailed assessment of the 
individual's presenting symptomatology, psychosocial profile, and other 
relevant factors. This assessment may lead to a determination that more 
than one treatment modality is appropriate for the individual. The 
treatment will be provided or overseen by an approved institution or 
facility. This treatment may include (but is not limited to)--
    (a) Medical examination and medical management;
    (b) Detoxification;
    (c) Medication management to include substitution therapy (e.g., 
methadone);
    (d) Psychiatric, psychological, psychosocial, vocational, or other 
substance abuse counseling in a residential or outpatient treatment 
setting; or
    (e) Relapse prevention.

[60 FR 8148, Feb. 10, 1995]



Sec. 404.1538  What we mean by approved institutions or facilities.

    Institutions or facilities that we may approve include--
    (a) An institution or facility that furnishes medically recognized 
treatment for drug addiction or alcoholism in conformity with applicable 
Federal or State laws and regulations;
    (b) An institution or facility used by or licensed by an appropriate 
State agency which is authorized to refer persons for treatment of drug 
addiction or alcoholism;
    (c) State licensed or certified care providers;
    (d) Programs accredited by the Commission on Accreditation for 
Rehabilitation Facilities (CARF) and/or the Joint Commission for the 
Accreditation of Healthcare Organizations

[[Page 337]]

(JCAHO) for the treatment of drug addiction or alcoholism;
    (e) Medicare or Medicaid certified care providers; or
    (f) Nationally recognized self-help drug addiction or alcoholism 
recovery programs (e.g., Alcoholics Anonymous or Narcotics Anonymous) 
when participation in these programs is specifically prescribed by a 
treatment professional at an institution or facility described in 
paragraphs (a) through (e) of this section as part of an individual's 
treatment plan.

[60 FR 8148, Feb. 10, 1995]



Sec. 404.1539  How we consider whether treatment is available.

    Our determination about whether treatment is available to you for 
your drug addiction or your alcoholism will depend upon--
    (a) The capacity of an approved institution or facility to admit you 
for appropriate treatment;
    (b) The location of the approved institution or facility, or the 
place where treatment, services or resources could be provided to you;
    (c) The availability and cost of transportation for you to the place 
of treatment;
    (d) Your general health, including your ability to travel and 
capacity to understand and follow the prescribed treatment;
    (e) Your particular condition and circumstances; and
    (f) The treatment that is prescribed for your drug addiction or 
alcoholism.

[60 FR 8148, Feb. 10, 1995]



Sec. 404.1540  Evaluating compliance with the treatment requirements.

    (a) General. Generally, we will consider information from the 
treatment institution or facility to evaluate your compliance with your 
treatment plan. The treatment institution or facility will:
    (1) Monitor your attendance at and participation in treatment 
sessions;
    (2) Provide reports of the results of any clinical testing (such as, 
hematological or urinalysis studies for individuals with drug addiction 
and hematological studies and breath analysis for individuals with 
alcoholism) when such tests are likely to yield important information;
    (3) Provide observational reports from the treatment professionals 
familiar with your individual case (subject to verification and Federal 
confidentiality requirements); or
    (4) Provide their assessment or views on your noncompliance with 
treatment requirements.
    (b) Measuring progress. Generally, we will consider information from 
the treatment institution or facility to evaluate your progress in 
completing your treatment plan. Examples of milestones for measuring 
your progress with the treatment which has been prescribed for your drug 
addiction or alcoholism may include (but are not limited to)--
    (1) Abstinence from drug or alcohol use (initial progress may 
include significant reduction in use);
    (2) Consistent attendance at and participation in treatment 
sessions;
    (3) Improved social functioning and levels of gainful activity;
    (4) Participation in vocational rehabilitation activities; or
    (5) Avoidance of criminal activity.

[60 FR 8148, Feb. 10, 1995]



Sec. 404.1541  Establishment and use of referral and monitoring agencies.

    We will contract with one or more agencies in each of the States, 
Puerto Rico and the District of Columbia to provide services to 
individuals whose disabilities are based on a determination that drug 
addiction or alcoholism is a contributing factor material to the 
determination of disability (as described in Sec. 404.1535) and to 
submit information to us which we will use to make decisions about these 
individuals' benefits. These agencies will be known as referral and 
monitoring agencies. Their duties and responsibilities include (but are 
not limited to)--
    (a) Identifying appropriate treatment placements for individuals we 
refer to them;
    (b) Referring these individuals for treatment;
    (c) Monitoring the compliance and progress with the appropriate 
treatment of these individuals; and

[[Page 338]]

    (d) Promptly reporting to us any individual's failure to comply with 
treatment requirements as well as failure to achieve progress through 
the treatment.

[60 FR 8148, Feb. 10, 1995]

                      Residual Functional Capacity



Sec. 404.1545  Your residual functional capacity.

    (a) General. Your impairment(s), and any related symptoms, such as 
pain, may cause physical and mental limitations that affect what you can 
do in a work setting. Your residual functional capacity is what you can 
still do despite your limitations. If you have more than one impairment, 
we will consider all of your impairment(s) of which we are aware. We 
will consider your ability to meet certain demands of jobs, such as 
physical demands, mental demands, sensory requirements, and other 
functions, as described in paragraphs (b), (c), and (d) of this section. 
Residual functional capacity is an assessment based upon all of the 
relevant evidence. It may include descriptions (even your own) of 
limitations that go beyond the symptoms, such as pain, that are 
important in the diagnosis and treatment of your medical condition. 
Observations by your treating or examining physicians or psychologists, 
your family, neighbors, friends, or other persons, of your limitations, 
in addition to those observations usually made during formal medical 
examinations, may also be used. These descriptions and observations, 
when used, must be considered along with your medical records to enable 
us to decide to what extent your impairment(s) keeps you from performing 
particular work activities. This assessment of your remaining capacity 
for work is not a decision on whether you are disabled, but is used as 
the basis for determining the particular types of work you may be able 
to do despite your impairment(s). Then, using the guidelines in 
Secs. 404.1560 through 404.1569a, your vocational background is 
considered along with your residual functional capacity in arriving at a 
disability determination or decision. In deciding whether your 
disability continues or ends, the residual functional capacity 
assessment may also be used to determine whether any medical improvement 
you have experienced is related to your ability to work as discussed in 
Sec. 404.1594.
    (b) Physical abilities. When we assess your physical abilities, we 
first assess the nature and extent of your physical limitations and then 
determine your residual functional capacity for work activity on a 
regular and continuing basis. A limited ability to perform certain 
physical demands of work activity, such as sitting, standing, walking, 
lifting, carrying, pushing, pulling, or other physical functions 
(including manipulative or postural functions, such as reaching, 
handling, stooping or crouching), may reduce your ability to do past 
work and other work.
    (c) Mental abilities. When we assess your mental abilities, we first 
assess the nature and extent of your mental limitations and restrictions 
and then determine your residual functional capacity for work activity 
on a regular and continuing basis. A limited ability to carry out 
certain mental activities, such as limitations in understanding, 
remembering, and carrying out instructions, and in responding 
appropriately to supervision, co-workers, and work pressures in a work 
setting, may reduce your ability to do past work and other work.
    (d) Other abilities affected by impairment(s). Some medically 
determinable impairment(s), such as skin impairment(s), epilepsy, 
impairment(s) of vision, hearing or other senses, and impairment(s) 
which impose environmental restrictions, may cause limitations and 
restrictions which affect other work-related abilities. If you have this 
type of impairment(s), we consider any resulting limitations and 
restrictions which may reduce your ability to do past work and other 
work in deciding your residual functional capacity.
    (e) Total limiting effects. When you have a severe impairment(s), 
but your symptoms, signs, and laboratory findings do not meet or equal 
those of a listed impairment in Appendix 1 of this subpart, we will 
consider the limiting effects of all your impairment(s), even those that 
are not severe, in determining your residual functional capacity.

[[Page 339]]

Pain or other symptoms may cause a limitation of function beyond that 
which can be determined on the basis of the anatomical, physiological or 
psychological abnormalities considered alone; e.g., someone with a low 
back disorder may be fully capable of the physical demands consistent 
with those of sustained medium work activity, but another person with 
the same disorder, because of pain, may not be capable of more than the 
physical demands consistent with those of light work activity on a 
sustained basis. In assessing the total limiting effects of your 
impairment(s) and any related symptoms, we will consider all of the 
medical and nonmedical evidence, including the information described in 
Sec. 404.1529(c).

[56 FR 57943, Nov, 14, 1991]



Sec. 404.1546  Responsibility for assessing and determining residual functional capacity.

    The State agency staff medical or psychological consultants or other 
medical or psychological consultants designated by the Secretary are 
responsible for ensuring that the State agency makes a decision about 
your residual functional capacity. In cases where the State agency makes 
the disability determination, a State agency staff medical or 
psychological consultant must assess residual functional capacity where 
it is required. This assessment is based on all of the evidence we have, 
including any statements regarding what you can still do that have been 
provided by treating or examining physicians, consultative physicians, 
or any other medical or psychological consultant designated by the 
Secretary. See Sec. 404.1545. For cases in the disability hearing 
process, the responsibility for deciding your residual functional 
capacity rests with either the disability hearing officer or, if the 
disability hearing officer's reconsidered determination is changed under 
Sec. 404.918, with the Director of the Office of Disability Hearings or 
his or her delegate. For cases at the Administrative Law Judge hearing 
or Appeals Council level, the responsibility for deciding your residual 
functional capacity rests with the Administrative Law Judge or Appeals 
Council.

[56 FR 36962, Aug. 1, 1991]

                        Vocational Considerations



Sec. 404.1560  When your vocational background will be considered.

    (a) General. If you are applying for a period of disability, or 
disability insurance benefits as a disabled worker, or child's insurance 
benefits based on disability which began before age 22, or widow's or 
widower's benefits based on disability for months after December 1990, 
and we cannot decide whether you are disabled on medical evidence alone, 
we will consider your residual functional capacity together with your 
vocational background.
    (b) Past relevant work. We will first compare your residual 
functional capacity with the physical and mental demands of the kind of 
work you have done in the past. If you still have the residual 
functional capacity to do your past relevant work, we will find that you 
can still do your past work, and we will determine that you are not 
disabled, without considering your vocational factors of age, education, 
and work experience.
    (c) Other work. If we find that you can no longer do the kind of 
work you have done in the past, we will then consider your residual 
functional capacity together with your vocational factors of age, 
education, and work experience to determine whether you can do other 
work. By other work we mean jobs that exist in significant numbers in 
the national economy.

[55 FR 11011, Mar. 26, 1990, as amended at 57 FR 30120, July 8, 1992]



Sec. 404.1561  Your ability to do work depends upon your residual functional capacity.

    If you can do your previous work (your usual work or other 
applicable past work), we will determine that you are not disabled. 
However, if your residual functional capacity is not enough to enable 
you to do any of your previous work, we must still decide if you can do 
any other work. To do this, we consider your residual functional 
capacity, and your age, education, and work experience. Any work (jobs) 
that

[[Page 340]]

you can do must exist in significant numbers in the national economy 
(either in the region where you live or in several regions of the 
country). Sections 404.1563 through 404.1565 explain how we evaluate 
your age, education, and work experience when we are deciding whether or 
not you are able to do other work.



Sec. 404.1562  If you have done only arduous unskilled physical labor.

    If you have only a marginal education and work experience of 35 
years or more during which you did arduous unskilled physical labor, and 
you are not working and are no longer able to do this kind of work 
because of a severe impairment(s), we will consider you unable to do 
lighter work, and therefore, disabled. However, if you are working or 
have worked despite your impairment(s) (except where the work is 
sporadic or is not medically advisable), we will review all the facts in 
your case, and we may find that you are not disabled. In addition, we 
will consider that you are not disabled if the evidence shows that you 
have training or past work experience which enables you to do 
substantial gainful activity in another occupation with your impairment, 
either on a full-time or a reasonably regular part-time basis.

    Example: B is a 60-year-old miner with a fourth grade education who 
has a life-long history of arduous physical labor. B says that he is 
disabled because of arthritis of the spine, hips, and knees, and other 
impairments. Medical evidence shows a combination of impairments and 
establishes that these impairments prevent B from performing his usual 
work or any other type of arduous physical labor. His vocational 
background does not show that he has skills or capabilities needed to do 
lighter work which would be readily transferable to another work 
setting. Under these circumstances, we will find that B is disabled.



Sec. 404.1563  Your age as a vocational factor.

    (a) General. Age refers to how old you are (your chronological age) 
and the extent to which your age affects your ability to adapt to a new 
work situation and to do work in competition with others. However, we do 
not determine disability on your age alone. We must also consider your 
residual functional capacity, education, and work experience. If you are 
unemployed because of your age and you can still do a significant number 
of jobs which exist in the national economy, we will find that you are 
not disabled. We explain in detail how we consider your age as a 
vocational factor in appendix 2. However, we will not apply these age 
categories mechanically in a borderline situation.
    (b) Younger person. If you are under age 50, we generally do not 
consider that your age will seriously affect your ability to adapt to a 
new work situation. In some circumstances, however, we consider age 45 a 
handicap in adapting to a new work setting (see Rule 201.17 in appendix 
2).
    (c) Person approaching advanced age. If you are closely approaching 
advanced age (50-54), we will consider that your age, along with a 
severe impairment and limited work experience, may seriously affect your 
ability to adjust to a significant number of jobs in the national 
economy.
    (d) Person of advanced age. We consider that advanced age (55 or 
over) is the point where age significantly affects a person's ability to 
do substantial gainful activity. If you are severely impaired and of 
advanced age and you cannot do medium work (see Sec. 404.1567(c)), you 
may not be able to work unless you have skills that can be used in 
(transferred to) less demanding jobs which exist in significant numbers 
in the national economy. If you are close to retirement age (60-64) and 
have a severe impairment, we will not consider you able to adjust to 
sedentary or light work unless you have skills which are highly 
marketable.
    (e) Information about your age. We will usually not ask you to prove 
your age. However, if we need to know your exact age to determine 
whether you get disability benefits or if the amount of your benefit 
will be affected, we will ask you for evidence of your age.



Sec. 404.1564  Your education as a vocational factor.

    (a) General. Education is primarily used to mean formal schooling or 
other training which contributes to your ability to meet vocational 
requirements, for example, reasoning ability,

[[Page 341]]

communication skills, and arithmetical ability. However, if you do not 
have formal schooling, this does not necessarily mean that you are 
uneducated or lack these abilities. Past work experience and the kinds 
of responsibilities you had when you were working may show that you have 
intellectual abilities, although you may have little formal education. 
Your daily activities, hobbies, or the results of testing may also show 
that you have significant intellectual ability that can be used to work.
    (b) How we evaluate your education. The importance of your 
educational background may depend upon how much time has passed between 
the completion of your formal education and the beginning of your 
physical or mental impairment(s) and by what you have done with your 
education in a work or other setting. Formal education that you 
completed many years before your impairment began, or unused skills and 
knowledge that were a part of your formal education, may no longer be 
useful or meaningful in terms of your ability to work. Therefore, the 
numerical grade level that you completed in school may not represent 
your actual educational abilities. These may be higher or lower. 
However, if there is no other evidence to contradict it, we will use 
your numerical grade level to determine your educational abilities. The 
term education also includes how well you are able to communicate in 
English since this ability is often acquired or improved by education. 
In evaluating your educational level, we use the following categories:
    (1) Illiteracy. Illiteracy means the inability to read or write. We 
consider someone illiterate if the person cannot read or write a simple 
message such as instructions or inventory lists even though the person 
can sign his or her name. Generally, an illiterate person has had little 
or no formal schooling.
    (2) Marginal education. Marginal education means ability in 
reasoning, arithmetic, and language skills which are needed to do 
simple, unskilled types of jobs. We generally consider that formal 
schooling at a 6th grade level or less is a marginal education.
    (3) Limited education. Limited education means ability in reasoning, 
arithmetic, and language skills, but not enough to allow a person with 
these educational qualifications to do most of the more complex job 
duties needed in semi-skilled or skilled jobs. We generally consider 
that a 7th grade through the 11th grade level of formal education is a 
limited education.
    (4) High school education and above. High school education and above 
means abilities in reasoning, arithmetic, and language skills acquired 
through formal schooling at a 12th grade level or above. We generally 
consider that someone with these educational abilities can do semi-
skilled through skilled work.
    (5) Inability to communicate in English. Since the ability to speak, 
read and understand English is generally learned or increased at school, 
we may consider this an educational factor. Because English is the 
dominant language of the country, it may be difficult for someone who 
doesn't speak and understand English to do a job, regardless of the 
amount of education the person may have in another language. Therefore, 
we consider a person's ability to communicate in English when we 
evaluate what work, if any, he or she can do. It generally doesn't 
matter what other language a person may be fluent in.
    (6) Information about your education. We will ask you how long you 
attended school and whether you are able to speak, understand, read and 
write in English and do at least simple calculations in arithmetic. We 
will also consider other information about how much formal or informal 
education you may have had through your previous work, community 
projects, hobbies, and any other activities which might help you to 
work.



Sec. 404.1565  Your work experience as a vocational factor.

    (a) General. Work experience means skills and abilities you have 
acquired through work you have done which show the type of work you may 
be expected to do. Work you have already been able to do shows the kind 
of work that you may be expected to do. We

[[Page 342]]

consider that your work experience applies when it was done within the 
last 15 years, lasted long enough for you to learn to do it, and was 
substantial gainful activity. We do not usually consider that work you 
did 15 years or more before the time we are deciding whether you are 
disabled (or when the disability insured status requirement was last 
met, if earlier) applies. A gradual change occurs in most jobs so that 
after 15 years it is no longer realistic to expect that skills and 
abilities acquired in a job done then continue to apply. The 15-year 
guide is intended to insure that remote work experience is not currently 
applied. If you have no work experience or worked only ``off-and-on'' or 
for brief periods of time during the 15-year period, we generally 
consider that these do not apply. If you have acquired skills through 
your past work, we consider you to have these work skills unless you 
cannot use them in other skilled or semi-skilled work that you can now 
do. If you cannot use your skills in other skilled or semi-skilled work, 
we will consider your work background the same as unskilled. However, 
even if you have no work experience, we may consider that you are able 
to do unskilled work because it requires little or no judgment and can 
be learned in a short period of time.
    (b) Information about your work. Under certain circumstances, we 
will ask you about the work you have done in the past. If you cannot 
give us all of the information we need, we will try, with your 
permission, to get it from your employer or other person who knows about 
your work, such as a member of your family or a co-worker. When we need 
to consider your work experience to decide whether you are able to do 
work that is different from what you have done in the past, we will ask 
you to tell us about all of the jobs you have had in the last 15 years. 
You must tell us the dates you worked, all of the duties you did, and 
any tools, machinery, and equipment you used. We will need to know about 
the amount of walking, standing, sitting, lifting and carrying you did 
during the work day, as well as any other physical or mental duties of 
your job. If all of your work in the past 15 years has been arduous and 
unskilled, and you have very little education, we will ask you to tell 
us about all of your work from the time you first began working. This 
information could help you to get disability benefits.



Sec. 404.1566  Work which exists in the national economy.

    (a) General. We consider that work exists in the national economy 
when it exists in significant numbers either in the region where you 
live or in several other regions of the country. It does not matter 
whether--
    (1) Work exists in the immediate area in which you live;
    (2) A specific job vacancy exists for you; or
    (3) You would be hired if you applied for work.
    (b) How we determine the existence of work. Work exists in the 
national economy when there is a significant number of jobs (in one or 
more occupations) having requirements which you are able to meet with 
your physical or mental abilities and vocational qualifications. 
Isolated jobs that exist only in very limited numbers in relatively few 
locations outside of the region where you live are not considered ``work 
which exists in the national economy''. We will not deny you disability 
benefits on the basis of the existence of these kinds of jobs. If work 
that you can do does not exist in the national economy, we will 
determine that you are disabled. However, if work that you can do does 
exist in the national economy, we will determine that you are not 
disabled.
    (c) Inability to obtain work. We will determine that you are not 
disabled if your residual functional capacity and vocational abilities 
make it possible for you to do work which exists in the national 
economy, but you remain unemployed because of--
    (1) Your inability to get work;
    (2) Lack of work in your local area;
    (3) The hiring practices of employers;
    (4) Technological changes in the industry in which you have worked;
    (5) Cyclical economic conditions;
    (6) No job openings for you;
    (7) You would not actually be hired to do work you could otherwise 
do; or

[[Page 343]]

    (8) You do not wish to do a particular type of work.
    (d) Administrative notice of job data. When we determine that 
unskilled, sedentary, light, and medium jobs exist in the national 
economy (in significant numbers either in the region where you live or 
in several regions of the country), we will take administrative notice 
of reliable job information available from various governmental and 
other publications. For example, we will take notice of--
    (1) Dictionary of Occupational Titles, published by the Department 
of Labor;
    (2) County Business Patterns, published by the Bureau of the Census;
    (3) Census Reports, also published by the Bureau of the Census;
    (4) Occupational Analyses, prepared for the Social Security 
Administration by various State employment agencies; and
    (5) Occupational Outlook Handbook, published by the Bureau of Labor 
Statistics.
    (e) Use of vocational experts and other specialists. If the issue in 
determining whether you are disabled is whether your work skills can be 
used in other work and the specific occupations in which they can be 
used, or there is a similarly complex issue, we may use the services of 
a vocational expert or other specialist. We will decide whether to use a 
vocational expert or other specialist.



Sec. 404.1567  Physical exertion requirements.

    To determine the physical exertion requirements of work in the 
national economy, we classify jobs as sedentary, light, medium, heavy, 
and very heavy. These terms have the same meaning as they have in the 
Dictionary of Occupational Titles, published by the Department of Labor. 
In making disability determinations under this subpart, we use the 
following definitions:
    (a) Sedentary work. Sedentary work involves lifting no more than 10 
pounds at a time and occasionally lifting or carrying articles like 
docket files, ledgers, and small tools. Although a sedentary job is 
defined as one which involves sitting, a certain amount of walking and 
standing is often necessary in carrying out job duties. Jobs are 
sedentary if walking and standing are required occasionally and other 
sedentary criteria are met.
    (b) Light work. Light work involves lifting no more than 20 pounds 
at a time with frequent lifting or carrying of objects weighing up to 10 
pounds. Even though the weight lifted may be very little, a job is in 
this category when it requires a good deal of walking or standing, or 
when it involves sitting most of the time with some pushing and pulling 
of arm or leg controls. To be considered capable of performing a full or 
wide range of light work, you must have the ability to do substantially 
all of these activities. If someone can do light work, we determine that 
he or she can also do sedentary work, unless there are additional 
limiting factors such as loss of fine dexterity or inability to sit for 
long periods of time.
    (c) Medium work. Medium work involves lifting no more than 50 pounds 
at a time with frequent lifting or carrying of objects weighing up to 25 
pounds. If someone can do medium work, we determine that he or she can 
also do sedentary and light work.
    (d) Heavy work. Heavy work involves lifting no more than 100 pounds 
at a time with frequent lifting or carrying of objects weighing up to 50 
pounds. If someone can do heavy work, we determine that he or she can 
also do medium, light, and sedentary work.
    (e) Very heavy work. Very heavy work involves lifting objects 
weighing more than 100 pounds at a time with frequent lifting or 
carrying of objects weighing 50 pounds or more. If someone can do very 
heavy work, we determine that he or she can also do heavy, medium, light 
and sedentary work.



Sec. 404.1568  Skill requirements.

    In order to evaluate your skills and to help determine the existence 
in the national economy of work you are able to do, occupations are 
classified as unskilled, semi-skilled, and skilled. In classifying these 
occupations, we use materials published by the Department of Labor. When 
we make disability determinations under this subpart, we use the 
following definitions:
    (a) Unskilled work. Unskilled work is work which needs little or no 
judgment to do simple duties that can be learned

[[Page 344]]

on the job in a short period of time. The job may or may not require 
considerable strength. For example, we consider jobs unskilled if the 
primary work duties are handling, feeding and offbearing (that is, 
placing or removing materials from machines which are automatic or 
operated by others), or machine tending, and a person can usually learn 
to do the job in 30 days, and little specific vocational preparation and 
judgment are needed. A person does not gain work skills by doing 
unskilled jobs.
    (b) Semi-skilled work. Semi-skilled work is work which needs some 
skills but does not require doing the more complex work duties. Semi-
skilled jobs may require alertness and close attention to watching 
machine processes; or inspecting, testing or otherwise looking for 
irregularities; or tending or guarding equipment, property, materials, 
or persons against loss, damage or injury; or other types of activities 
which are similarly less complex than skilled work, but more complex 
than unskilled work. A job may be classified as semi-skilled where 
coordination and dexterity are necessary, as when hands or feet must be 
moved quickly to do repetitive tasks.
    (c) Skilled work. Skilled work requires qualifications in which a 
person uses judgment to determine the machine and manual operations to 
be performed in order to obtain the proper form, quality, or quantity of 
material to be produced. Skilled work may require laying out work, 
estimating quality, determining the suitability and needed quantities of 
materials, making precise measurements, reading blueprints or other 
specifications, or making necessary computations or mechanical 
adjustments to control or regulate the work. Other skilled jobs may 
require dealing with people, facts, or figures or abstract ideas at a 
high level of complexity.
    (d) Skills that can be used in other work (transferability)--(1) 
What we mean by transferable skills. We consider you to have skills that 
can be used in other jobs, when the skilled or semi-skilled work 
activities you did in past work can be used to meet the requirements of 
skilled or semi-skilled work activities of other jobs or kinds of work. 
This depends largely on the similarity of occupationally significant 
work activities among different jobs.
    (2) How we determine skills that can be transferred to other jobs. 
Transferability is most probable and meaningful among jobs in which--
    (i) The same or a lesser degree of skill is required;
    (ii) The same or similar tools and machines are used; and
    (iii) The same or similar raw materials, products, processes, or 
services are involved.
    (3) Degrees of transferability. There are degrees of transferability 
of skills ranging from very close similarities to remote and incidental 
similarities among jobs. A complete similarity of all three factors is 
not necessary for transferability. However, when skills are so 
specialized or have been acquired in such an isolated vocational setting 
(like many jobs in mining, agriculture, or fishing) that they are not 
readily usable in other industries, jobs, and work settings, we consider 
that they are not transferable.



Sec. 404.1569  Listing of Medical-Vocational Guidelines in Appendix 2.

    The Dictionary of Occupational Titles includes information about 
jobs (classified by their exertional and skill requirements) that exist 
in the national economy. Appendix 2 provides rules using this data 
reflecting major functional and vocational patterns. We apply these 
rules in cases where a person is not doing substantial gainful activity 
and is prevented by a severe medically determinable impairment from 
doing vocationally relevant past work. The rules in appendix 2 do not 
cover all possible variations of factors. Also, as we explain in 
Sec. 200.00 of appendix 2, we do not apply these rules if one of the 
findings of fact about the person's vocational factors and residual 
functional capacity is not the same as the corresponding criterion of a 
rule. In these instances, we give full consideration to all relevant 
facts in accordance with the definitions and discussions under 
vocational considerations. However, if the findings of fact made about 
all factors are the same as the rule, we use that rule to decide whether 
a person is disabled.

[[Page 345]]



Sec. 404.1569a  Exertional and nonexertional limitations.

    (a) General. Your impairment(s) and related symptoms, such as pain, 
may cause limitations of function or restrictions which limit your 
ability to meet certain demands of jobs. These limitations may be 
exertional, nonexertional, or a combination of both. Limitations are 
classified as exertional if they affect your ability to meet the 
strength demands of jobs. The classification of a limitation as 
exertional is related to the United States Department of Labor's 
classification of jobs by various exertional levels (sedentary, light, 
medium, heavy, and very heavy) in terms of the strength demands for 
sitting, standing, walking, lifting, carrying, pushing, and pulling. 
Sections 404.1567 and 404.1569 explain how we use the classification of 
jobs by exertional levels (strength demands) which is contained in the 
Dictionary of Occupational Titles published by the Department of Labor, 
to determine the exertional requirements of work which exists in the 
national economy. Limitations or restrictions which affect your ability 
to meet the demands of jobs other than the strength demands, that is, 
demands other than sitting, standing, walking, lifting, carrying, 
pushing or pulling, are considered nonexertional. Sections 404.1520(f) 
and 404.1594(f)(8) explain that if you can no longer do your past 
relevant work because of a severe medically determinable impairment(s), 
we must determine whether your impairment(s), when considered along with 
your age, education, and work experience, prevents you from doing any 
other work which exists in the national economy in order to decide 
whether you are disabled (Sec. 404.1520(f)) or continue to be disabled 
(Sec. 404.1594(f)(8)). Paragraphs (b), (c), and (d) of this section 
explain how we apply the medical-vocational guidelines in Appendix 2 of 
this subpart in making this determination, depending on whether the 
limitations or restrictions imposed by your impairment(s) and related 
symptoms, such as pain, are exertional, nonexertional, or a combination 
of both.
    (b) Exertional limitations. When the limitations and restrictions 
imposed by your impairment(s) and related symptoms, such as pain, affect 
only your ability to meet the strength demands of jobs (sitting, 
standing, walking, lifting, carrying, pushing, and pulling), we consider 
that you have only exertional limitations. When your impairment(s) and 
related symptoms only impose exertional limitations and your specific 
vocational profile is listed in a rule contained in Appendix 2 of this 
subpart, we will directly apply that rule to decide whether you are 
disabled.
    (c) Nonexertional limitations. (1) When the limitations and 
restrictions imposed by your impairment(s) and related symptoms, such as 
pain, affect only your ability to meet the demands of jobs other than 
the strength demands, we consider that you have only nonexertional 
limitations or restrictions. Some examples of nonexertional limitations 
or restrictions include the following:
    (i) You have difficulty functioning because you are nervous, 
anxious, or depressed;
    (ii) You have difficulty maintaining attention or concentrating;
    (iii) You have difficulty understanding or remembering detailed 
instructions;
    (iv) You have difficulty in seeing or hearing;
    (v) You have difficulty tolerating some physical feature(s) of 
certain work settings, e.g., you cannot tolerate dust or fumes; or
    (vi) You have difficulty performing the manipulative or postural 
functions of some work such as reaching, handling, stooping, climbing, 
crawling, or crouching.
    (2) If your impairment(s) and related symptoms, such as pain, only 
affect your ability to perform the nonexertional aspects of work-related 
activities, the rules in appendix 2 do not direct factual conclusions of 
disabled or not disabled. The determination as to whether disability 
exists will be based on the principles in the appropriate sections of 
the regulations, giving consideration to the rules for specific case 
situations in appendix 2.
    (d) Combined exertional and nonexertional limitations. When the 
limitations and restrictions imposed by your impairment(s) and related 
symptoms, such as pain, affect your ability to meet both the strength 
and demands of jobs other than the strength demands, we consider that 
you have a combination of exertional and nonexertional limitations or 
restrictions. If

[[Page 346]]

your impairment(s) and related symptoms, such as pain, affect your 
ability to meet both the strength and demands of jobs other than the 
strength demands, we will not directly apply the rules in appendix 2 
unless there is a rule that directs a conclusion that you are disabled 
based upon your strength limitations; otherwise the rules provide a 
framework to guide our decision.

[56 FR 57943, Nov, 14, 1991]

                      Substantial Gainful Activity



Sec. 404.1571  General.

    The work that you have done during any period in which you believe 
you are disabled may show that you are able to do work at the 
substantial gainful activity level. If you are able to engage in 
substantial gainful activity, we will find that you are not disabled. 
(We explain the rules for persons who are statutorily blind in 
Sec. 404.1584.) Even if the work you have done was not substantial 
gainful activity, it may show that you are able to do more work than you 
actually did. We will consider all of the medical and vocational 
evidence in your file to decide whether or not you have the ability to 
engage in substantial gainful activity.



Sec. 404.1572  What we mean by substantial gainful activity.

    Substantial gainful activity is work activity that is both 
substantial and gainful:
    (a) Substantial work activity. Substantial work activity is work 
activity that involves doing significant physical or mental activities. 
Your work may be substantial even if it is done on a part-time basis or 
if you do less, get paid less, or have less responsibility than when you 
worked before.
    (b) Gainful work activity. Gainful work activity is work activity 
that you do for pay or profit. Work activity is gainful if it is the 
kind of work usually done for pay or profit, whether or not a profit is 
realized.
    (c) Some other activities. Generally, we do not consider activities 
like taking care of yourself, household tasks, hobbies, therapy, school 
attendance, club activities, or social programs to be substantial 
gainful activity.



Sec. 404.1573  General information about work activity.

    (a) The nature of your work. If your duties require use of your 
experience, skills, supervision and responsibilities, or contribute 
substantially to the operation of a business, this tends to show that 
you have the ability to work at the substantial gainful activity level.
    (b) How well you perform. We consider how well you do your work when 
we determine whether or not you are doing substantial gainful activity. 
If you do your work satisfactorily, this may show that you are working 
at the substantial gainful activity level. If you are unable, because of 
your impairments, to do ordinary or simple tasks satisfactorily without 
more supervision or assistance than is usually given other people doing 
similar work, this may show that you are not working at the substantial 
gainful activity level. If you are doing work that involves minimal 
duties that make little or no demands on you and that are of little or 
no use to your employer, or to the operation of a business if you are 
self-employed, this does not show that you are working at the 
substantial gainful activity level.
    (c) If your work is done under special conditions. Even though the 
work you are doing takes into account your impairment, such as work done 
in a sheltered workshop or as a patient in a hospital, it may still show 
that you have the necessary skills and ability to work at the 
substantial gainful activity level.
    (d) If you are self-employed. Supervisory, managerial, advisory or 
other significant personal services that you perform as a self-employed 
individual may show that you are able to do substantial gainful 
activity.
    (e) Time spent in work. While the time you spend in work is 
important, we will not decide whether or not you are doing substantial 
gainful activity only

[[Page 347]]

on that basis. We will still evaluate the work to decide whether it is 
substantial and gainful regardless of whether you spend more time or 
less time at the job than workers who are not impaired and who are doing 
similar work as a regular means of their livelihood.



Sec. 404.1574  Evaluation guides if you are an employee.

    (a) General. We use several guides to decide whether the work you 
have done shows that you are able to do substantial gainful activity.
    (1) Your earnings may show you have done substantial gainful 
activity. The amount of your earnings from work you have done may show 
that you have engaged in substantial gainful activity. Generally, if you 
worked for substantial earnings, this will show that you are able to do 
substantial gainful activity. On the other hand, the fact that your 
earnings are not substantial will not necessarily show that you are not 
able to do substantial gainful activity. We will generally consider work 
that you are forced to stop after a short time because of your 
impairment as an unsuccessful work attempt and your earnings from that 
work will not show that you are able to do substantial gainful activity.
    (2) We consider only the amounts you earn. We do not consider any 
income not directly related to your productivity when we decide whether 
you have done substantial gainful activity. If your earnings are being 
subsidized, the amount of the subsidy is not counted when we determine 
whether or not your work is substantial gainful activity. Thus, where 
work is done under special conditions, we only consider the part of your 
pay which you actually earn. For example, where a handicapped person 
does simple tasks under close and continuous supervision, we would not 
determine that the person worked at the substantial gainful activity 
level only on the basis of the amount of pay. An employer may set a 
specific amount as a subsidy after figuring the reasonable value of the 
employee's services. If your work is subsidized and your employer does 
not set the amount of the subsidy or does not adequately explain how the 
subsidy was figured, we will investigate to see how much your work is 
worth.
    (3) If you are working in a sheltered or special environment. If you 
are working in a sheltered workshop, you may or may not be earning the 
amounts you are being paid. The fact that the sheltered workshop or 
similar facility is operating at a loss or is receiving some charitable 
contributions or governmental aid does not establish that you are not 
earning all you are being paid. Since persons in military service being 
treated for severe impairments usually continue to receive full pay, we 
evaluate work activity in a therapy program or while on limited duty by 
comparing it with similar work in the civilian work force or on the 
basis of reasonable worth of the work, rather than on the actual amount 
of the earnings.
    (b) Earnings guidelines. (1) General. If you are an employee, we 
first consider the criteria in paragraph (a) of this section and 
Sec. 404.1576, and then the guides in paragraphs (b) (2), (3), (4), (5), 
and (6) of this section.
    (2) Earnings that will ordinarily show that you have engaged in 
substantial gainful activity. We will consider that your earnings from 
your work activities as an employee show that you have engaged in 
substantial gainful activity if--
    (i) Your earnings averaged more than $200 a month in calendar years 
prior to 1976;
    (ii) Your earnings averaged more than $230 a month in calendar year 
1976;
    (iii) Your earnings averaged more than $240 a month in calendar year 
1977;
    (iv) Your earnings averaged more than $260 a month in calendar year 
1978;
    (v) Your earnings averaged more than $280 a month in calendar year 
1979;
    (vi) Your earnings averaged more than $300 a month in calendar years 
after 1979 and before 1990; or
    (vii) Your earnings averaged more than $500 a month in calendar 
years after 1989.
    (3) Earnings that will ordinarily show that you have not engaged in 
substantial gainful activity. We will generally consider that the 
earnings from your work

[[Page 348]]

as an employee will show that you have not engaged in substantial 
gainful activity if--
    (i) Your earnings averaged less than $130 a month in calendar years 
before 1976;
    (ii) Your earnings averaged less than $150 a month in calendar year 
1976;
    (iii) Your earnings averaged less than $160 a month in calendar year 
1977;
    (iv) Your earnings averaged less than $170 a month in calendar year 
1978;
    (v) Your earnings averaged less than $180 a month in calendar year 
1979;
    (vi) Your earnings averaged less than $190 a month in calendar years 
after 1979 and before 1990; or
    (vii) Your earnings averaged less than $300 a month in calendar 
years after 1989.
    (4) If you work in a sheltered workshop. If you are working in a 
sheltered workshop or a comparable facility especially set up for 
severely impaired persons, your earnings and activities will ordinarily 
establish that you have not done substantial gainful activity if--
    (i) Your average earnings are not greater than $200 a month in 
calendar years prior to 1976;
    (ii) Your average earnings are not greater than $230 a month in 
calendar year 1976;
    (iii) Your average earnings are not greater than $240 a month in 
calendar year 1977;
    (iv) Your average earnings are not greater than $260 a month in 
calendar year 1978;
    (v) Your average earnings are not greater than $280 a month in 
calendar year 1979;
    (vi) Your average earnings are not greater than $300 a month in 
calendar years after 1979 and before 1990; or
    (vii) Your average earnings are not greater than $500 a month in 
calendar years after 1989.
    (5) If there is evidence showing that you may have done substantial 
gainful activity. If there is evidence showing that you may have done 
substantial gainful activity, we will apply the criteria in paragraph 
(b)(6) of this section regarding comparability and value of services.
    (6) Earnings that are not high or low enough to show whether you 
engaged in substantial gainful activity. If your earnings, on the 
average, are between the amounts shown in paragraphs (b)(2) and (3) of 
this section, we will generally consider other information in addition 
to your earnings, such as whether--
    (i) Your work is comparable to that of unimpaired people in your 
community who are doing the same or similar occupations as their means 
of livelihood, taking into account the time, energy, skill, and 
responsibility involved in the work, or
    (ii) Your work, although significantly less than that done by 
unimpaired people, is clearly worth the amounts shown in paragraph 
(b)(2) of this section, according to pay scales in your community.

[46 FR 4869, Jan. 19, 1981, as amended at 48 FR 21936, May 16, 1983; 49 
FR 22272, May 29, 1984; 54 FR 53605, Dec. 29, 1989]



Sec. 404.1575  Evaluation guides if you are self-employed.

    (a) If you are a self-employed person. We will consider your 
activities and their value to your business to decide whether you have 
engaged in substantial gainful activity if you are self-employed. We 
will not consider your income alone since the amount of income you 
actually receive may depend upon a number of different factors like 
capital investment, profit sharing agreements, etc. We will generally 
consider work that you are forced to stop after a short time because of 
your impairment as an unsuccessful work attempt and your income from 
that work will not show that you are able to do substantial gainful 
activity. We will evaluate your work activity on the value to the 
business of your services regardless of whether you receive an immediate 
income for your services. We consider that you have engaged in 
substantial gainful activity if--
    (1) Your work activity, in terms of factors such as hours, skills, 
energy output, efficiency, duties, and responsibilities, is comparable 
to that of unimpaired individuals in your community who are in the same 
or similar businesses as their means of livelihood;
    (2) Your work activity, although not comparable to that of 
unimpaired individuals, is clearly worth the amount

[[Page 349]]

shown in Sec. 404.1574(b)(2) when considered in terms of its value to 
the business, or when compared to the salary that an owner would pay to 
an employee to do the work you are doing; or
    (3) You render services that are significant to the operation of the 
business and receive a substantial income from the business.
    (b) What we mean by significant services. (1) If you are not a farm 
landlord and you operate a business entirely by yourself, any services 
that you render are significant to the business. If your business 
involves the services of more than one person, we will consider you to 
be rendering significant services if you contribute more than half the 
total time required for the management of the business, or you render 
management services for more than 45 hours a month regardless of the 
total management time required by the business.
    (2) If you are a farm landlord, that is, you rent farm land to 
another, we will consider you to be rendering significant services if 
you materially particpate in the production or the management of the 
production of the things raised on the rented farm. (See Sec. 404.1082 
of this chapter for an explanation of material participation.) If you 
were given social security earnings credits because you materially 
participated in the activities of the farm and you continue these same 
activities, we will consider you to be rendering significant services.
    (c) What we mean by substantial income. After your normal business 
expenses are deducted from your gross income to determine net income, we 
will deduct the reasonable value of any unpaid help, any soil bank 
payments that were included as farm income, and impairment-related work 
expenses described in Sec. 404.1576 that have not been deducted in 
determining your net earnings from self-employment. We will consider the 
resulting amount of income from the business to be substantial if--
    (1) It averages more than the amounts described in 
Sec. 404.1574(b)(2); or
    (2) It averages less than the amounts described in 
Sec. 404.1574(b)(2) but the livelihood which you get from the business 
is either comparable to what it was before you became severely impaired 
or is comparable to that of unimpaired self-employed persons in your 
community who are in the same or similar business as their means of 
livelihood.

[46 FR 4870, Jan. 19, 1981, as amended at 48 FR 21936, May 16, 1983; 49 
FR 22272, May 29, 1984]



Sec. 404.1576  Impairment-related work expenses.

    (a) General. When we figure your earnings in deciding if you have 
done substantial gainful activity, we will subtract the reasonable costs 
to you of certain items and services which, because of your 
impairment(s), you need and use to enable you to work. The costs are 
deductible even though you also need or use the items and services to 
carry out daily living functions unrelated to your work. Paragraph (b) 
of this section explains the conditions for deducting work expenses. 
Paragraph (c) of this section describes the expenses we will deduct. 
Paragraph (d) of this section explains when expenses may be deducted. 
Paragraph (e) of this section describes how expenses may be allocated. 
Paragraph (f) of this section explains the limitations on deducting 
expenses. Paragraph (g) of this section explains our verification 
procedures.
    (b) Conditions for deducting impairment-related work expenses. We 
will deduct impairment-related work expenses if--
    (1) You are otherwise disabled as defined in Secs. 404.1505, 
404.1577 and 404.1581-404.1583;
    (2) The severity of your impairment(s) requires you to purchase (or 
rent) certain items and services in order to work;
    (3) You pay the cost of the item or service. No deduction will be 
allowed to the extent that payment has been or will be made by another 
source. No deduction will be allowed to the extent that you have been, 
could be, or will be reimbursed for such cost by any other source (such 
as through a private insurance plan, Medicare or Medicaid, or other plan 
or agency). For example, if you purchase crutches for $80 but you were, 
could be, or will be reimbursed $64 by some agency, plan, or program, we 
will deduct only $16;

[[Page 350]]

    (4) You pay for the item or service in a month you are working (in 
accordance with paragraph (d) of this section); and
    (5) Your payment is in cash (including checks or other forms of 
money). Payment in kind is not deductible.
    (c) What expenses may be deducted--(1) Payments for attendant care 
services. (i) If because of your impairment(s) you need assistance in 
traveling to and from work, or while at work you need assistance with 
personal functions (e.g., eating, toileting) or with work-related 
functions (e.g., reading, communicating), the payments you make for 
those services may be deducted.
    (ii) If because of your impairment(s) you need assistance with 
personal functions (e.g., dressing, administering medications) at home 
in preparation for going to and assistance in returning from work, the 
payments you make for those services may be deducted.
    (iii)(A) We will deduct payments you make to a family member for 
attendant care services only if such person, in order to perform the 
services, suffers an economic loss by terminating his or her employment 
or by reducing the number of hours he or she worked.
    (B) We consider a family member to be anyone who is related to you 
by blood, marriage or adoption, whether or not that person lives with 
you.
    (iv) If only part of your payment to a person is for services that 
come under the provisions of paragraph (c)(1) of this section, we will 
only deduct that part of the payment which is attributable to those 
services. For example, an attendant gets you ready for work and helps 
you in returning from work, which takes about 2 hours a day. The rest of 
his or her 8 hour day is spent cleaning your house and doing your 
laundry, etc. We would only deduct one-fourth of the attendant's daily 
wages as an impairment-related work expense.
    (2) Payments for medical devices. If your impairment(s) requires 
that you utilize medical devices in order to work, the payments you make 
for those devices may be deducted. As used in this subparagraph, medical 
devices include durable medical equipment which can withstand repeated 
use, is customarily used for medical purposes, and is generally not 
useful to a person in the absence of an illness or injury. Examples of 
durable medical equipment are wheelchairs, hemodialysis equipment, 
canes, crutches, inhalators and pacemakers.
    (3) Payments for prosthetic devices. If your impairment(s) requires 
that you utilize a prosthetic device in order to work, the payments you 
make for that device may be deducted. A prosthetic device is that which 
replaces an internal body organ or external body part. Examples of 
prosthetic devices are artificial replacements of arms, legs and other 
parts of the body.
    (4) Payments for equipment. (i) Work-related equipment. If your 
impairment(s) requires that you utilize special equipment in order to do 
your job, the payments you make for that equipment may be deducted. 
Examples of work-related equipment are one-hand typewriters, vision 
aids, sensory aids for the blind, telecommunication devices for the deaf 
and tools specifically designed to accommodate a person's impairment(s).
    (ii) Residential modifications. If your impairment(s) requires that 
you make modifications to your residence, the location of your place of 
work will determine if the cost of these modifications will be deducted. 
If you are employed away from home, only the cost of changes made 
outside of your home to permit you to get to your means of 
transportation (e.g., the installation of an exterior ramp for a 
wheelchair confined person or special exterior railings or pathways for 
someone who requires crutches) will be deducted. Costs relating to 
modifications of the inside of your home will not be deducted. If you 
work at home, the costs of modifying the inside of your home in order to 
create a working space to accommodate your impairment(s) will be 
deducted to the extent that the changes pertain specifically to the 
space in which you work. Examples of such changes are the enlargement of 
a doorway leading into the workspace or modification of the workspace to 
accommodate problems in dexterity. However, if you are self-employed at 
home, any cost deducted as a business expense cannot be deducted as an 
impairment-related work expense.

[[Page 351]]

    (iii) Nonmedical appliances and equipment. Expenses for appliances 
and equipment which you do not ordinarily use for medical purposes are 
generally not deductible. Examples of these items are portable room 
heaters, air conditioners, humidifiers, dehumidifiers, and electric air 
cleaners. However, expenses for such items may be deductible when 
unusual circumstances clearly establish an impairment-related and 
medically verified need for such an item because it is essential for the 
control of your disabling condition, thus enabling you to work. To be 
considered essential, the item must be of such a nature that if it were 
not available to you there would be an immediate adverse impact on your 
ability to function in your work activity. In this situation, the 
expense is deductible whether the item is used at home or in the working 
place. An example would be the need for an electric air cleaner by an 
individual with severe respiratory disease who cannot function in a non-
purified air environment. An item such as an exercycle is not deductible 
if used for general physical fitness. If it is prescribed and used as 
necessary treatment of your impairment and necessary to enable you to 
work, we will deduct payments you make toward its cost.
    (5) Payments for drugs and medical services. (i) If you must use 
drugs or medical services (including diagnostic procedures) to control 
your impairment(s) the payments you make for them may be deducted. The 
drugs or services must be prescribed (or utilized) to reduce or 
eliminate symptoms of your impairment(s) or to slow down its 
progression. The diagnostic procedures must be performed to ascertain 
how the impairment(s) is progressing or to determine what type of 
treatment should be provided for the impairment(s).
    (ii) Examples of deductible drugs and medical services are 
anticonvulsant drugs to control epilepsy or anticonvulsant blood level 
monitoring; antidepressant medication for mental disorders; medication 
used to allay the side effects of certain treatments; radiation 
treatment or chemotherapy for cancer patients; corrective surgery for 
spinal disorders; electroencephalograms and brain scans related to a 
disabling epileptic condition; tests to determine the efficacy of 
medication on a diabetic condition; and immunosuppressive medications 
that kidney transplant patients regularly take to protect against graft 
rejection.
    (iii) We will only deduct the costs of drugs or services that are 
directly related to your impairment(s). Examples of non-deductible items 
are routine annual physical examinations, optician services (unrelated 
to a disabling visual impairment) and dental examinations.
    (6) Payments for similar items and services--(i) General. If you are 
required to utilize items and services not specified in paragraphs (c) 
(1) through (5) of this section but which are directly related to your 
impairment(s) and which you need to work, their costs are deductible. 
Examples of such items and services are medical supplies and services 
not discussed above, the purchase and maintenance of a dog guide which 
you need to work, and transportation.
    (ii) Medical supplies and services not described above. We will 
deduct payments you make for expendable medical supplies, such as 
incontinence pads, catheters, bandages, elastic stockings, face masks, 
irrigating kits, and disposable sheets and bags. We will also deduct 
payments you make for physical therapy which you require because of your 
impairment(s) and which you need in order to work.
    (iii) Payments for transportation costs. We will deduct 
transportation costs in these situations:
    (A) Your impairment(s) requires that in order to get to work you 
need a vehicle that has structural or operational modifications. The 
modifications must be critical to your operation or use of the vehicle 
and directly related to your impairment(s). We will deduct the costs of 
the modifications, but not the cost of the vehicle. We will also deduct 
a mileage allowance for the trip to and from work. The allowance will be 
based on data compiled by the Federal Highway Administration relating to 
vehicle operating costs.
    (B) Your impairment(s) requires you to use driver assistance, 
taxicabs or other hired vehicles in order to work.

[[Page 352]]

We will deduct amounts paid to the driver and, if your own vehicle is 
used, we will also deduct a mileage allowance, as provided in paragraph 
(c)(6)(iii)(A) of this section, for the trip to and from work.
    (C) Your impairment(s) prevents your taking available public 
transportation to and from work and you must drive your (unmodified) 
vehicle to work. If we can verify through your physician or other 
sources that the need to drive is caused by your impairment(s) (and not 
due to the unavailability of public transportation), we will deduct a 
mileage allowance, as provided in paragraph (c)(6)(iii)(A) of this 
section, for the trip to and from work.
    (7) Payments for installing, maintaining, and repairing deductible 
items. If the device, equipment, appliance, etc., that you utilize 
qualifies as a deductible item as described in paragraphs (c) (2), (3), 
(4) and (6) of this section, the costs directly related to installing, 
maintaining and repairing these items are also deductible. (The costs 
which are associated with modifications to a vehicle are deductible. 
Except for a mileage allowance, as provided for in paragraph (c)(6)(iii) 
of this section, the costs which are associated with the vehicle itself 
are not deductible.)
    (d) When expenses may be deducted. (1) Effective date. To be 
deductible an expense must be incurred after November 30, 1980. An 
expense may be considered incurred after that date if it is paid 
thereafter even though pursuant to a contract or other arrangement 
entered into before December 1, 1980.
    (2) Payments for services. A payment you make for services may be 
deducted if the services are received while you are working and the 
payment is made in a month you are working. We consider you to be 
working even though you must leave work temporarily to receive the 
services.
    (3) Payments for items. A payment you make toward the cost of a 
deductible item (regardless of when it is acquired) may be deducted if 
payment is made in a month you are working. See paragraph (e)(4) of this 
section when purchases are made in anticipation of work.
    (e) How expenses are allocated. (1) Recurring expenses. You may pay 
for services on a regular periodic basis, or you may purchase an item on 
credit and pay for it in regular periodic installments or you may rent 
an item. If so, each payment you make for the services and each payment 
you make toward the purchase or rental (including interest) is 
deductible in the month it is made.

    Example. B starts work in October 1981 at which time she purchases a 
medical device at a cost of $4,800 plus interest charges of $720. Her 
monthly payments begin in October. She earns and receives $400 a month. 
The term of the installment contract is 48 months. No downpayment is 
made. The monthly allowable deduction for the item would be $115 ($5520 
divided by 48) for each month of work during the 48 months.

    (2) Nonrecurring expenses. Part or all of your expenses may not be 
recurring. For example, you may make a one-time payment in full for an 
item or service or make a downpayment. If you are working when you make 
the payment we will either deduct the entire amount in the month you pay 
it or allocate the amount over a 12 consecutive month period beginning 
with the month of payment, whichever you select.

    Example.  A begins working in October 1981 and earns $525 a month. 
In the same month he purchases and pays for a deductible item at a cost 
of $250. In this situation we could allow a $250 deduction for October 
1981, reducing A's earnings below the SGA level for that month.
    If A's earnings had been $15 above the SGA earnings amount, A 
probably would select the option of projecting the $250 payment over the 
12-month period, October 1981-September 1982, giving A an allowable 
deduction of $20.83 a month for each month of work during that period. 
This deduction would reduce A's earnings below the SGA level for 12 
months.

    (3) Allocating downpayments. If you make a downpayment we will, if 
you choose, make a separate calculation for the downpayment in order to 
provide for uniform monthly deductions. In these situations we will 
determine the total payment that you will make over a 12 consecutive 
month period beginning with the month of the downpayment and allocate 
that amount over the 12 months. Beginning with the 13th month, the 
regular monthly payment will be deductible. This allocation process will 
be for a shorter period

[[Page 353]]

if your regular monthly payments will extend over a period of less than 
12 months.

    Example 1. C starts working in October 1981, at which time he 
purchases special equipment at a cost of $4,800, paying $1,200 down. The 
balance of $3,600, plus interest of $540, is to be repaid in 36 
installments of $115 a month beginning November 1981. C earns $500 a 
month. He chooses to have the downpayment allocated. In this situation 
we would allow a deduction of $205.42 a month for each month of work 
during the period October 1981 through September 1982. After September 
1982, the deduction amount would be the regular monthly payment of $115 
for each month of work during the remaining installment period.

Explanation:                                                            
  Downpayment in 10/81..........................      $1,200            
  Monthly payments 11/81 through 09/82..........       1,265            
                                                 ------------           
                                                   12) 2,465    =$205.42
                                                                        

    Example 2. D, while working, buys a deductible item in July 1981, 
paying $1,450 down. However, his first monthly payment of $125 is not 
due until September 1981. D chooses to have the downpayment allocated. 
In this situation we would allow a deduction of $225 a month for each 
month of work during the period July 1981 through June 1982. After June 
1982, the deduction amount would be the regular monthly payment of $125 
for each month of work.

Explanation:                                                            
  Downpayment in 07/81..........................      $1,450            
  Monthly payments 09/81 through 06/82..........       1,250            
                                                 ------------           
                                                   12) 2,700       =$225
                                                                        

    (4) Payments made in anticipation of work. A payment toward the cost 
of a deductible item that you made in any of the 11 months preceding the 
month you started working will be taken into account in determining your 
impairment-related work expenses. When an item is paid for in full 
during the 11 months preceding the month you started working the payment 
will be allocated over the 12-consecutive month period beginning with 
the month of the payment. However, the only portion of the payment which 
may be deductible is the portion allocated to the month work begins and 
the following months. For example, if an item is purchased 3 months 
before the month work began and is paid for with a one-time payment of 
$600, the deductible amount would be $450 ($600 divided by 12, 
multiplied by 9). Installment payments (including a downpayment) that 
you made for a particular item during the 11 months preceding the month 
you started working will be totaled and considered to have been made in 
the month of your first payment for that item within this 11 month 
period. The sum of these payments will be allocated over the 12-
consecutive month period beginning with the month of your first payment 
(but never earlier than 11 months before the month work began). However, 
the only portion of the total which may be deductible is the portion 
allocated to the month work begins and the following months. For 
example, if an item is purchased 3 months before the month work began 
and is paid for in 3 monthly installments of $200 each, the total 
payment of $600 will be considered to have been made in the month of the 
first payment, that is, 3 months before the month work began. The 
deductible amount would be $450 ($600 divided by 12, multiplied by 9). 
The amount, as determined by these formulas, will then be considered to 
have been paid in the first month of work. We will deduct either this 
entire amount in the first month of work or allocate it over a 12-
consecutive month period beginning with the first month of work, 
whichever you select. In the above examples, the individual would have 
the choice of having the entire $450 deducted in the first month of work 
or of having $37.50 a month ($450 divided by 12) deducted for each month 
that he works over a 12-consecutive month period, beginning with the 
first month of work. To be deductible the payments must be for durable 
items such as medical devices, prostheses, work-related equipment, 
residential modifications, nonmedical appliances and vehicle 
modifications. Payments for services and expendable items such as drugs, 
oxygen, diagnostic procedures, medical supplies and vehicle operating 
costs are not deductible for purposes of this paragraph.
    (f) Limits on deductions. (1) We will deduct the actual amounts you 
pay towards your impairment-related work

[[Page 354]]

expenses unless the amounts are unreasonable. With respect to durable 
medical equipment, prosthetic devices, medical services, and similar 
medically-related items and services, we will apply the prevailing 
charges under Medicare (part B of title XVIII, Health Insurance for the 
Aged and Disabled) to the extent that this information is readily 
available. Where the Medicare guides are used, we will consider the 
amount that you pay to be reasonable if it is no more than the 
prevailing charge for the same item or service under the Medicare 
guidelines. If the amount you actually pay is more than the prevailing 
charge for the same item under the Medicare guidelines, we will deduct 
from your earnings the amount you paid to the extent you establish that 
the amount is consistent with the standard or normal charge for the same 
or similar item or service in your community. For items and services 
that are not listed in the Medicare guidelines, and for items and 
services that are listed in the Medicare guidelines but for which such 
guides cannot be used because the information is not readily available, 
we will consider the amount you pay to be reasonable if it does not 
exceed the standard or normal charge for the same or similar item(s) or 
service(s) in your community.
    (2) Impairment-related work expenses are not deducted in computing 
your earnings for purposes of determining whether your work was 
``services'' as described in Sec. 404.1592(b).
    (3) The decision as to whether you performed substantial gainful 
activity in a case involving impairment-related work expenses for items 
or services necessary for you to work generally will be based upon your 
``earnings'' and not on the value of ``services'' you rendered. (See 
Secs. 404.1574(b)(6) (i) and (ii), and 404.1575(a)). This is not 
necessarily so, however, if you are in a position to control or 
manipulate your earnings.
    (4) The amount of the expenses to be deducted must be determined in 
a uniform manner in both the disability insurance and SSI programs.
    (5) No deduction will be allowed to the extent that any other source 
has paid or will pay for an item or service. No deduction will be 
allowed to the extent that you have been, could be, or will be, 
reimbursed for payments you made. (See paragraph (b)(3) of this 
section.)
    (6) The provisions described in the foregoing paragraphs of this 
section are effective with respect to expenses incurred on and after 
December 1, 1980, although expenses incurred after November 1980 as a 
result of contractual or other arrangements entered into before December 
1980, are deductible. For months before December 1980 we will deduct 
impairment-related work expenses from your earnings only to the extent 
they exceeded the normal work-related expenses you would have had if you 
did not have your impairment(s). We will not deduct expenses, however, 
for those things which you needed even when you were not working.
    (g) Verification. We will verify your need for items or services for 
which deductions are claimed, and the amount of the charges for those 
items or services. You will also be asked to provide proof that you paid 
for the items or services.

[48 FR 21936, May 16, 1983]

            Widows, Widowers, and Surviving Divorced Spouses



Sec. 404.1577  Disability defined for widows, widowers, and surviving divorced spouses for monthly benefits payable for months prior to January 1991.

    For monthly benefits payable for months prior to January 1991, the 
law provides that to be entitled to a widow's or widower's benefit as a 
disabled widow, widower, or surviving divorced spouse, you must have a 
medically determinable physical or mental impairment which can be 
expected to result in death or has lasted or can be expected to last for 
a continuous period of not less than 12 months. The impairment(s) must 
have been of a level of severity to prevent a person from doing any 
gainful activity. To determine whether you were disabled, we consider 
only your physical or mental impairment(s). We do not consider your age, 
education, and work experience. We also do not consider certain felony-
related and prison-related impairments, as explained in Sec. 404.1506. 
(For

[[Page 355]]

monthly benefits payable for months after December 1990, see 
Sec. 404.1505(a).)

[57 FR 30120, July 8, 1992]



Sec. 404.1578  How we determine disability for widows, widowers, and surviving divorced spouses for monthly benefits payable for months prior to January 1991.

    (a) For monthly benefits payable for months prior to January 1991, 
we will find that you were disabled and pay you widow's or widower's 
benefits as a widow, widower, or surviving divorced spouse if--
    (1) Your impairment(s) had specific clinical findings that were the 
same as those for any impairment in the Listing of Impairments in 
appendix 1 of this subpart or were medically equivalent to those for any 
impairment shown there;
    (2) Your impairment(s) met the duration requirement.
    (b) However, even if you met the requirements in paragraphs (a) (1) 
and (2) of this section, we will not find you disabled if you were doing 
substantial gainful activity.

[57 FR 30121, July 8, 1992]



Sec. 404.1579  How we will determine whether your disability continues or ends.

    (a) General. (1) The rules for determining whether disability 
continues for widow's or widower's monthly benefits for months after 
December 1990 are discussed in Secs. 404.1594 through 404.1598. The 
rules for determining whether disability continues for monthly benefits 
for months prior to January 1991 are discussed in paragraph (a)(2) of 
this section and paragraphs (b) through (h) of this section.
    (2) If you are entitled to disability benefits as a disabled widow, 
widower, or surviving divorced spouse, and we must decide whether your 
disability continued or ended for monthly benefits for months prior to 
January 1991, there are a number of factors we consider in deciding 
whether your disability continued. We must determine if there has been 
any medical improvement in your impairment(s) and, if so, whether this 
medical improvement is related to your ability to work. If your 
impairment(s) has not so medically improved, we must address whether one 
or more exceptions applies. If medical improvement related to your 
ability to work has not occurred and no exception applies, your benefits 
will continue. Even where medical improvement related to your ability to 
work has occurred or an exception applies, in most cases (see paragraph 
(e) of this section for exceptions) before we can find that you are no 
longer disabled, we must also show that your impairment(s), as shown by 
current medical evidence, is no longer deemed, under appendix 1 of this 
subpart, sufficient to preclude you from engaging in gainful activity.
    (b) Terms and definitions. There are several terms and definitions 
which are important to know in order to understand how we review your 
claim to determine whether your disability continues.
    (1) Medical improvement. Medical improvement is any decrease in the 
medical severity of your impairment(s) which was present at the time of 
the most recent favorable medical decision that you were disabled or 
continued to be disabled. A determination that there has been a decrease 
in medical severity must be based on changes (improvement) in the 
symptoms, signs and/or laboratory findings (see Sec. 404.1528) 
associated with your impairment(s).

    Example 1: You were awarded disability benefits due to a herniated 
nucleus pulposus which was determined to equal the level of severity 
contemplated by Listing 1.05.C. At the time of our prior favorable 
decision, you had had a laminectomy. Postoperatively, a myelogram still 
showed evidence of a persistent deficit in your lumbar spine. You had 
pain in your back, and pain and a burning sensation in your right foot 
and leg. There were no muscle weakness or neurological changes and a 
modest decrease in motion in your back and leg. When we reviewed your 
claim your treating physician reported that he had seen you regularly 
every 2 to 3 months for the past 2 years. No further myelograms had been 
done, complaints of pain in the back and right leg continued especially 
on sitting or standing for more than a short period of time. Your doctor 
further reported a moderately decreased range of motion in your back and 
right leg, but again no muscle atrophy or neurological changes were 
reported. Medical improvement has not occurred because there has been no 
decrease in the severity of your back impairment as

[[Page 356]]

shown by changes in symptoms, signs, or laboratory findings.
    Example 2: You were awarded disability benefits due to rheumatoid 
arthritis of a severity as described in Listing 1.02 of appendix 1 of 
this subpart. At the time, laboratory findings were positive for this 
condition. Your doctor reported persistent swelling and tenderness of 
your fingers and wrists and that you complained of joint pain. Current 
medical evidence shows that while laboratory tests are still positive 
for rheumatoid arthritis, your impairment has responded favorably to 
therapy so that for the last year your fingers and wrists have not been 
significantly swollen or painful. Medical improvement has occurred 
because there has been a decrease in the severity of your impairment as 
documented by the current symptoms and signs reported by your physician. 
Although your impairment is subject to temporary remissions and 
exacerbations the improvement that has occurred has been sustained long 
enough to permit a finding of medical improvement. We would then 
determine if this medical improvement is related to your ability to 
work.

    (2) Determining whether medical improvement is related to your 
ability to work. If medical improvement has occurred and the severity of 
the prior impairment(s) no longer meets or equals the listing section 
which was used in making our most recent favorable decision, we will 
find that the medical improvement was related to your ability to work. 
We make this finding because the criteria in appendix 1 of this subpart 
are related to ability to work because they reflect impairments which 
are considered severe enough to prevent a person from doing any gainful 
work. We must, of course, also establish that, considering all of your 
current impairments not just those which existed at the time of the most 
recent prior favorable medical decision, your condition does not meet or 
equal the requirements of appendix 1 before we could find that your 
disability has ended. If there has been any medical improvement in your 
impairment(s), but it is not related to your ability to do work and none 
of the exceptions applies, your benefits will be continued.
    (3) Determining whether your impairment(s) is deemed, under appendix 
1 of this subpart, sufficient to preclude you from engaging in gainful 
activity. Even where medical improvement related to your ability to work 
has occurred or an exception applies, in most cases before we can find 
that you are no longer disabled, we must also show that your 
impairment(s) is no longer deemed, under appendix 1 of this subpart, 
sufficient to preclude you from engaging in gainful activity. All 
current impairments will be considered, not just the impairment(s) 
present at the time of our most recent favorable determination. Sections 
404.1525, 404.1526, and 404.1578 set out how we will decide whether your 
impairment(s) meets or equals the requirements of appendix 1 of this 
subpart.
    (4) Evidence and basis for our decision. Our decisions under this 
section will be made on a neutral basis without any initial inference as 
to the presence or absence of disability being drawn from the fact that 
you have previously been determined to be disabled. We will consider all 
evidence you submit, as well as all evidence we obtain from your 
treating physician(s) and other medical or nonmedical sources. What 
constitutes ``evidence'' and our procedures for obtaining it are set out 
in Secs. 404.1512 through 404.1518. Our determination regarding whether 
your disability continues will be made on the basis of the weight of the 
evidence.
    (5) Point of comparison. For purposes of determining whether medical 
improvement has occurred, we will compare the current severity of that 
impairment(s) which was present at the time of the most recent favorable 
medical decision that you were disabled or continued to be disabled to 
the medical severity of that impairment(s) at that time. If medical 
improvement has occurred, we will determine whether the medical 
improvement is related to your ability to do work based on this 
previously existing impairment(s). The most recent favorable medical 
decision is the latest decision involving a consideration of the medical 
evidence and the issue of whether you were disabled or continued to be 
disabled which became final.
    (c) Determining medical improvement and its relationship to your 
ability to do work. Paragraphs (b) (1) and (2) of this section discuss 
what we mean by medical improvement and how we determine whether medical 
improvement is related to your ability to work.

[[Page 357]]

    (1) Medical improvement. Medical improvement is any decrease in the 
medical severity of impairment(s) present at the time of the most recent 
favorable medical decision that you were disabled or continued to be 
disabled. Whether medical improvement has occurred is determined by a 
comparison of prior and current medical evidence which must show that 
there have been changes (improvement) in the symptoms, signs or 
laboratory findings associated with that impairment(s).
    (2) Determining whether medical improvement is related to ability to 
work. If there is a decrease in medical severity as shown by the signs, 
symptoms and laboratory findings, we then must determine if it is 
related to your ability to do work, as explained in paragraph (b)(2) of 
this section. In determining if the medical improvement that has 
occurred is related to your ability to work, we will assess whether the 
previously existing impairments still meet or equal the level of 
severity contemplated by the same listing section in appendix 1 of this 
subpart which was used in making our most recent favorable decision. 
Appendix 1 of this subpart describes impairments which, if severe 
enough, affect a person's ability to work. If the appendix level of 
severity is met or equaled, the individual is deemed, in the absence of 
evidence of the contrary, to be unable to engage in gainful activity. If 
there has been medical improvement to the degree that the requirement of 
the listing section is no longer met or equaled, then the medical 
improvement is related to your ability to work. Unless an objective 
assessment shows that the listing requirement is no longer met or 
equaled based on actual changes shown by the medical evidence, the 
medical improvement that has occurred will not be considered to be 
related to your ability to work.
    (3) Prior file cannot be located. If the prior file cannot be 
located, we will first determine whether your current impairment(s) is 
deemed, under appendix 1 of this subpart, sufficient to preclude you 
from engaging in gainful activity. (In this way, we will be able to 
determine that your disability continues at the earliest time without 
addressing the issue of reconstructing prior evidence which can be a 
lengthy process.) If so, your benefits will continue unless one of the 
second group of exceptions applies (see paragraph (e) of this section). 
If not, we will determine whether an attempt should be made to 
reconstruct those portions of the file that were relevant to our most 
recent favorable medical decision (e.g., medical evidence from treating 
sources and the results of consultative examinations). This 
determination will consider the potential availability of old records in 
light of their age, whether the source of the evidence is still in 
operation, etc.; and whether reconstruction efforts will yield a 
complete record of the basis for the most recent favorable medical 
decision. If relevant parts of the prior record are not reconstructed 
either because it is determined not to attempt reconstruction or because 
such efforts fail, medical improvement cannot be found. The 
documentation of your current impairments will provide a basis for any 
future reviews. If the missing file is later found, it may serve as a 
basis for reopening any decision under this section in accordance with 
the rules in Sec. 404.988.
    (4) Impairment(s) subject to temporary remission. In some cases the 
evidence shows that an individual's impairment is subject to temporary 
remission. In assessing whether medical improvement has occurred in 
persons with this type of impairment, we will be careful to consider the 
longitudinal history of the impairment(s), including the occurrence of 
prior remissions, and prospects for future worsening of the 
impairment(s). Improvement in such impairments that is only temporary 
will not warrant a finding of medical improvement.
    (5) Applicable listing has been revised since the most recent 
favorable medical decision. When determining whether any medical 
improvement is related to your ability to work, we use the same listing 
section in appendix 1 of this subpart which was used to make our prior 
favorable decision. We will use the listing as it appeared at the time 
of the prior decision, even where the requirement(s) of the listing was 
subsequently changed. The current revised listing requirement will be 
used if we

[[Page 358]]

determine that you have medically improved and it is necessary to 
determine whether you are now considered unable to engage in gainful 
activity.
    (d) First group of exceptions to medical improvement. The law 
provides for certain limited situations when your disability can be 
found to have ended even though medical improvement has not occurred, if 
your impairment(s) is no longer considered, under appendix 1 of this 
subpart, sufficient to preclude you from engaging in gainful activity. 
These exceptions to medical improvement are intended to provide a way of 
finding that a person is no longer disabled in those limited situations 
where, even though there has been no decrease in severity of the 
impairment(s), evidence shows that the person should no longer be 
considered disabled or never should have been considered disabled. If 
one of these exceptions applies, before we can find you are no longer 
disabled, we must also show that, taking all your current impairment(s) 
into account, not just those that existed at the time of our most recent 
favorable medical decision, your impairment(s) is no longer deemed, 
under appendix 1 of this subpart, sufficient to preclude you from 
engaging in gainful activity. As part of the review process, you will be 
asked about any medical therapy you received or are receiving. Your 
answers and the evidence gathered as a result as well as all other 
evidence, will serve as the basis for the finding that an exception does 
or does not apply.
    (1) Substantial evidence shows that you are the beneficiary of 
advances in medical therapy or technology (related to your ability to 
work). Advances in medical therapy or technology are improvements in 
treatment or rehabilitative methods which have favorably affected the 
severity of your impairment(s). We will apply this exception when 
substantial evidence shows that you have been the beneficiary of 
services which reflect these advances and they have favorably affected 
the severity of your impairment(s). This decision will be based on new 
medical evidence. In many instances, an advanced medical therapy or 
technology will result in a decrease in severity as shown by symptoms, 
signs and laboratory findings which will meet the definition of medical 
improvement. This exception will, therefore, see very limited 
application.
    (2) Substantial evidence shows that based on new or improved 
diagnostic or evaluative techniques your impairment(s) is not as 
disabling as it was considered to be at the time of the most recent 
favorable decision. Changing methodologies and advances in medical and 
other diagnostic or evaluative techniques have given, and will continue 
to give, rise to improved methods for measuring and documenting the 
effect of various impairments on the ability to do work. Where, by such 
new or improved methods, substantial evidence shows that your 
impairment(s) is not as severe as was determined at the time of our most 
recent favorable medical decision, such evidence may serve as a basis 
for finding that you are no longer disabled, if your impairment(s) is no 
longer deemed, under appendix 1 of this subpart, sufficient to preclude 
you from engaging in gainful activity. In order to be used under this 
exception, however, the new or improved techniques must have become 
generally available after the date of our most recent favorable medical 
decision.
    (i) How we will determine which methods are new or improved 
techniques and when they become generally available. New or improved 
diagnostic techniques or evaluations will come to our attention by 
several methods. In reviewing cases, we often become aware of new 
techniques when their results are presented as evidence. Such techniques 
and evaluations are also discussed and acknowledged in medical 
literature by medical professional groups and other governmental 
entities. Through these sources, we develop listings of new techniques 
and when they become generally available. For example, we will consult 
the Health Care Financing Administration for its experience regarding 
when a technique is recognized for payment under Medicare and when they 
began paying for the technique.
    (ii) How you will know which methods are new or improved techniques 
and when they become generally available. We will let you know which 
methods we consider to be new or improved techniques and when they 
become available through two vehicles.

[[Page 359]]

    (A) Some of the future changes in the Listing of Impairments in 
appendix 1 of this subpart will be based on new or improved diagnostic 
or evaluative techniques. Such listing changes will clearly state this 
fact as they are published as Notices of Proposed Rulemaking and the new 
or improved technique will be considered generally available as of the 
date of the final publication of that particular listing in the Federal 
Register.
    (B) A cumulative list since 1970 of new or improved diagnostic 
techniques or evaluations, how they changed the evaluation of the 
applicable impairment and the month and year they became generally 
available, will be published in the Notices section of the Federal 
Register. Included will be any changes in the Listing of Impairments 
published in the Code of Federal Regulations since 1970 which are 
reflective of new or improved techniques. No cases will be processed 
under this exception until this cumulative listing is so published. 
Subsequent changes to the list will be published periodically. The 
period will be determined by the volume of changes needed.

    Example: The electrocardiographic exercise test has replaced the 
Master's 2-step test as a measurement of heart function since the time 
of your last favorable medical decision. Current evidence could show 
that your condition, which was previously evaluated based on the 
Master's 2-step test, is not now as disabling as was previously thought. 
If, taking all your current impairments into account, you are now able 
to engage in gainful activity, this exception would be used to find that 
you are no longer disabled even if medical improvement has not occurred.

    (3) Substantial evidence demonstrates that any prior disability 
decision was in error. We will apply the exception to medical 
improvement based on error if substantial evidence (which may be 
evidence on the record at the time any prior determination of the 
entitlement to benefits based on disability was made, or newly obtained 
evidence which relates to that determination) demonstrates that a prior 
determination was in error. A prior determination will be found in error 
only if:
    (i) Substantial evidence shows on its face that the decision in 
question should not have been made (e.g., the evidence in your file such 
as pulmonary function study values was misread or an adjudicative 
standard such as a listing in appendix 1 of this subpart was 
misapplied).

    Example: You were granted benefits when it was determined that your 
epilepsy met Listing 11.02. This listing calls for a finding of major 
motor seizures more frequently than once a month as documented by EEG 
evidence and by a detailed description of a typical seizure pattern. A 
history of either diurnal episodes or nocturnal episodes with residuals 
interfering with daily activities is also required. On review, it is 
found that a history of the frequency of your seizures showed that they 
occurred only once or twice a year. The prior decision would be found to 
be in error, and whether you were still considered to be disabled would 
be based on whether your current impairment(s) meets or equals the 
requirements of appendix 1 of this subpart.

    (ii) At the time of the prior evaluation, required and material 
evidence of the severity of your impairment(s) was missing. That 
evidence becomes available upon review, and substantial evidence 
demonstrates that had such evidence been present at the time of the 
prior determination, disability would not have been found.
    (iii) Substantial evidence which is new evidence which relates to 
the prior determination (of allowance or continuance) refutes the 
conclusions that were based upon the prior evidence (e.g., a tumor 
thought to be malignant was later shown to have actually been benign). 
Substantial evidence must show that had the new evidence (which relates 
to the prior determination) been considered at the time of the prior 
decision, the claim would not have been allowed or continued. A 
substitution of current judgment for that used in the prior favorable 
decision will not be the basis for applying this exception.

    Example: You were previously granted disability benefits on the 
basis of diabetes mellitus which the prior adjudicator believed was 
equivalent to the level of severity contemplated in the Listing of 
Impairments. The prior record shows that you had ``brittle'' diabetes 
for which you were taking insulin. Your urine was 3+ for sugar, and you 
alleged occasional hypoglycemic attacks caused by exertion. On review, 
symptoms, signs and laboratory findings are unchanged. The current 
adjudicator believes, however, that your impairment does not equal the 
severity contemplated by the listings. Error cannot be found because it 
would represent a substitution of current judgment for that of

[[Page 360]]

the prior adjudicator that your impairment equaled a listing.

    (iv) The exception for error will not be applied retroactively under 
the conditions set out above unless the conditions for reopening the 
prior decision (see Sec. 404.988) are met.
    (4) You are currently engaging in substantial gainful activity. If 
you are currently engaging in substantial gainful activity before we 
determine whether you are no longer disabled because of your work 
activity, we will consider whether you are entitled to a trial work 
period as set out in Sec. 404.1592. We will find that your disability 
has ended in the month in which you demonstrated your ability to engage 
in substantial gainful activity (following completion of a trial work 
period, where it applies). This exception does not apply in determining 
whether you continue to have a disabling impairment(s) (Sec. 404.1511) 
for purposes of deciding your eligibility for a reentitlement period 
(Sec. 404.1592a).
    (e) Second group of exceptions to medical improvement. In addition 
to the first group of exceptions to medical improvement, the following 
exceptions may result in a determination that you are no longer 
disabled. In these situations the decision will be made without a 
determination that you have medically improved or can engage in gainful 
activity.
    (1) A prior determination or decision was fraudulently obtained. If 
we find that any prior favorable determination or decision was obtained 
by fraud, we may find that you are not disabled. In addition, we may 
reopen your claim under the rules in Sec. 404.988. In determining 
whether a prior favorable determination or decision was fraudulently 
obtained, we will take into account any physical, mental, educational, 
or linguistic limitations (including any lack of facility with the 
English language) which you may have had at the time.
    (2) You do not cooperate with us. If there is a question about 
whether you continue to be disabled and we ask you to give us medical or 
other evidence or to go for a physical or mental examination by a 
certain date, we will find that your disability has ended if you fail, 
without good cause, to do what we ask. Section 404.911 explains the 
factors we consider and how we will determine generally whether you have 
good cause for failure to cooperate. In addition, Sec. 404.1518 
discusses how we determine whether you have good cause for failing to 
attend a consultative examination. The month in which your disability 
ends will be the first month in which you failed to do what we asked.
    (3) We are unable to find you. If there is a question about whether 
you continue to be disabled and we are unable to find you to resolve the 
question, we will determine that your disability has ended. The month 
your disability ends will be the first month in which the question arose 
and we could not find you.
    (4) You fail to follow prescribed treatment which would be expected 
to restore your ability to engage in gainful activity. If treatment has 
been prescribed for you which would be expected to restore your ability 
to work, you must follow that treatment in order to be paid benefits. If 
you are not following that treatment and you do not have good cause for 
failing to follow that treatment, we will find that your disability has 
ended (see Sec. 404.1530(c)). The month your disability ends will be the 
first month in which you failed to follow the prescribed treatment.
    (f) Evaluation steps. To assure that disability reviews are carried 
out in a uniform manner, that decisions of continuing disability can be 
made in the most expeditious and administratively efficient way, and 
that any decisions to stop disability benefits are made objectively, 
neutrally and are fully documented, we will follow specific steps in 
reviewing the question of whether your disability continues. Our review 
may stop and benefits may be continued at any point if we determine 
there is sufficient evidence to find that you are still unable to engage 
in gainful activity. The steps are:
    (1) Are you engaging in substantial gainful activity? If you are 
(and any applicable trial work period has been completed), we will find 
disability to have ended.
    (2) If you are not, has there been medical improvement as defined in 
paragraph (b)(1) of this section? If there has been medical improvement 
as

[[Page 361]]

shown by a decrease in medical severity, see step (3). If there has been 
no decrease in medical severity, there has been no medical improvement. 
(see step (4).)
    (3) If there has been medical improvement, we must determine (in 
accordance with paragraph (b)(2) of this section) whether it is related 
to your ability to work. If medical improvement is not related to your 
ability to do work, see step (4). If medical improvement is related to 
your ability to do work, see step (5).
    (4) If we found at step (2) that there has been no medical 
improvement or if we found at step (3) that the medical improvement is 
not related to your ability to work, we consider whether any of the 
exceptions in paragraphs (d) and (e) of this section apply. If none of 
them apply, your disability will be found to continue. If one of the 
first group of exceptions to medical improvement (see paragraph (d) of 
this section) applies, we will proceed to step (5). If an exception from 
the second group of exceptions to medical improvement applies, your 
disability will be found to have ended. The second group of exceptions 
to medical improvement may be considered at any point in this process.
    (5) If medical improvement is related to your ability to work or if 
one of the first group of exceptions to medical improvement applies, we 
will determine (considering all your impairments) whether the 
requirements of appendix 1 of this subpart are met or equaled. If your 
impairment(s) meets or equals the requirements of appendix 1 of this 
subpart, your disability will be found to continue. If not, your 
disability will be found to have ended.
    (g) The month in which we will find you are no longer disabled. If 
the evidence shows that you are no longer disabled, we will find that 
your disability ended in the earliest of the following months--
    (1) The month the evidence shows you are no longer disabled under 
the rules set out in this section, and you were disabled only for a 
specified period of time in the past;
    (2) The month the evidence shows you are no longer disabled under 
the rules set out in this section, but not earlier than the month in 
which we mail you a notice saying that the information we have shows 
that you are not disabled;
    (3) The month in which you demonstrated your ability to engage in 
substantial gainful activity (following completion of a trial work 
period); however, we may pay you benefits for certain months in and 
after the reentitlement period which follows the trial work period. (See 
Sec. 404.1592 for a discussion of the trial work period, Sec. 404.1592a 
for a discussion of the reentitlement period, and Sec. 404.337 for when 
your benefits will end.);
    (4) The month in which you return to full-time work, with no 
significant medical restrictions and acknowledge that medical 
improvement has occurred, as long as we expected your impairment(s) to 
improve (see Sec. 404.1591);
    (5) The first month in which you failed to do what we asked, without 
good cause when the rule set out in paragraph (e)(2) of this section 
applies;
    (6) The first month in which the question of continuing disability 
arose and we could not find you, when the rule set out in paragraph 
(e)(3) of this section applies;
    (7) The first month in which you failed to follow prescribed 
treatment without good cause, when the rule set out in paragraph (e)(4) 
of this section applies; or
    (8) The first month you were told by your physician that you could 
return to work provided there is no substantial conflict between your 
physician's and your statements regarding your awareness of your 
capacity for work and the earlier date is supported by medical evidence.
    (h) Before we stop your benefits. Before we determine you are no 
longer disabled, we will give you a chance to explain why we should not 
do so. Sections 404.1595 and 404.1597 describe your rights (including 
appeal rights) and the procedures we will follow.

[50 FR 50126, Dec. 6, 1985; 51 FR 7063, Feb. 28, 1986; 51 FR 16015, Apr. 
30, 1986, as amended at 57 FR 30121, July 8, 1992; 59 FR 1635, Jan. 12, 
1994]

                                Blindness

[[Page 362]]



Sec. 404.1581  Meaning of blindness as defined in the law.

    We will consider you blind under the law for a period of disability 
and for payment of disability insurance benefits if we determine that 
you are statutorily blind. Statutory blindness is defined in the law as 
central visual acuity of 20/200 or less in the better eye with the use 
of correcting lens. An eye which has a limitation in the field of vision 
so that the widest diameter of the visual field subtends an angle no 
greater than 20 degrees is considered to have a central visual acuity of 
20/200 or less. Your blindness must meet the duration requirement in 
Sec. 404.1509. We do not consider certain felony-related and prison-
related impairments, as explained in Sec. 404.1506.

[45 FR 55584, Aug. 20, 1980, as amended at 48 FR 5715, Feb. 8, 1983]



Sec. 404.1582  A period of disability based on blindness.

    If we find that you are blind and you meet the insured status 
requirement, we may establish a period of disability for you regardless 
of whether you can do substantial gainful activity. A period of 
disability protects your earnings record under Social Security so that 
the time you are disabled will not count against you in determining 
whether you will have worked long enough to qualify for benefits and the 
amount of your benefits. However, you will not necessarily be entitled 
to receive disability insurance cash benefits even though you are blind. 
If you are a blind person under age 55, you must be unable to do any 
substantial gainful activity in order to be paid disability insurance 
cash benefits.



Sec. 404.1583  How we determine disability for blind persons who are age 55 or older.

    We will find that you are eligible for disability insurance benefits 
even though you are still engaging in substantial gainful activity, if--
    (a) You are blind;
    (b) You are age 55 or older; and
    (c) You are unable to use the skills or abilities like the ones you 
used in any substantial gainful activity which you did regularly and for 
a substantial period of time. (However, you will not be paid any cash 
benefits for any month in which you are doing substantial gainful 
activity.)



Sec. 404.1584  Evaluation of work activity of blind people.

    (a) General. If you are blind (as explained in Sec. 404.1581), we 
will consider the earnings from the work you are doing to determine 
whether or not you should be paid cash benefits.
    (b) Under Age 55. If you are under age 55, we will evaluate the work 
you are doing using the guides in paragraph (d) of this section to 
determine whether or not your work shows that you are doing substantial 
gainful activity. If you are not doing substantial gainful activity, we 
will pay you cash benefits. If you are doing substantial gainful 
activity, we will not pay you cash benefits. However, you will be given 
a period of disability as described in subpart D of this part.
    (c) Age 55 or older. If you are age 55 or older, we will evaluate 
your work using the guides in paragraph (d) of this section to determine 
whether or not your work shows that you are doing substantial gainful 
activity. If you have not shown this ability, we will pay you cash 
benefits. If you have shown an ability to do substantial gainful 
activity, we will evaluate your work activity to find out how your work 
compares with the work you did before. If the skills and abilities of 
your new work are about the same as those you used in the work you did 
before, we will not pay you cash benefits. However, if your new work 
requires skills and abilities which are less than or different than 
those you used in the work you did before, we will pay you cash 
benefits, but not for any month in which you actually perform 
substantial gainful activity.
    (d) Evaluation of earnings. The law provides a different earnings 
test for substantial gainful activity of people who are blind. We will 
not consider that you are able to engage in substantial gainful activity 
on the basis of earnings unless your monthly earnings average more than 
$334.00 in 1978; $375.00 in 1979; $417.00 in 1980; $459.00 in 1981; and 
$500.00 in 1982. (Sections

[[Page 363]]

404.1574(a)(2), 404.1575(c) and 404.1576 are applicable in determining 
the amount of your earnings.) Thereafter, an increase in the substantial 
gainful activity amount will depend on increases in the cost of living. 
For work activity performed in taxable years before 1978, the earnings 
considered enough to show an ability to do substantial gainful activity 
are the same for blind people as for others.

[45 FR 55584, Aug. 20, 1980, as amended at 48 FR 21939, May 16, 1983]



Sec. 404.1585  Trial work period for persons age 55 or older who are blind.

    If you become eligible for disability benefits even though you were 
doing substantial gainful activity because you are blind and age 55 or 
older, you are entitled to a trial work period if--
    (a) You later return to substantial gainful activity that requires 
skills or abilities comparable to those required in the work you 
regularly did before you became blind or became 55 years old, whichever 
is later; or
    (b) Your last previous work ended because of an impairment and the 
current work requires a significant vocational adjustment.



Sec. 404.1586  Why and when we will stop your cash benefits.

    (a) When you are not entitled to benefits. If you become entitled to 
disability cash benefits as a statutorily blind person, we will find 
that you are no longer entitled to benefits beginning with the earliest 
of--
    (1) The month your vision, based on current medical evidence, does 
not meet the definition of blindness and your disability does not 
continue under the rules in Sec. 404.1594 and you were disabled only for 
a specified period of time in the past;
    (2) The month your vision, based on current medical evidence, does 
not meet the definition of blindness and your disability does not 
continue under the rules in Sec. 404.1594, but not earlier than the 
month in which we mail you a notice saying that the information we have 
shows that you are not disabled;
    (3) If you are under age 55, the month in which you demonstrated 
your ability to engage in substantial gainful activity (following 
completion of a trial work period); however, we may pay you benefits for 
certain months in and after the reentitlement period which follows the 
trial work period. (See Sec. 404.1592a for a discussion of the 
reentitlement period, and Sec. 404.316 on when your benefits will end.); 
or
    (4) If you are age 55 or older, the month (following completion of a 
trial work period) when your work activity shows you are able to use, in 
substantial gainful activity, skills and abilities comparable to those 
of some gainful activity which you did with some regularity and over a 
substantial period of time. The skills and abilities are compared to the 
activity you did prior to age 55 or prior to becoming blind, whichever 
is later.
    (b) If we find that you are not entitled to disability cash 
benefits. If we find that you are not entitled to disability cash 
benefits on the basis of your work activity but your visual impairment 
is sufficiently severe to meet the definition of blindness, the period 
of disability that we established for you will continue.
    (c) If you do not follow prescribed treatment. If treatment has been 
prescribed for you that can restore your ability to work, you must 
follow that treatment in order to be paid benefits. If you are not 
following that treatment and you do not have a good reason for failing 
to follow that treatment (see Sec. 404.1530(c)), we will find that your 
disability has ended. The month in which your disability will be found 
to have ended will be the first month in which you failed to follow the 
prescribed treatment.
    (d) If you do not cooperate with us. If we ask you to give us 
medical or other evidence or to go for a medical examination by a 
certain date, we will find that your disability has ended if you fail, 
without good cause, to do what we ask. Section 404.911 explains the 
factors we consider and how we will determine generally whether you have 
good cause for failure to cooperate. In addition, Sec. 404.1518 
discusses how we determine whether you have good cause for failing to 
attend a consultative examination. The month in which your disability 
will be found to have ended will be the month in which you failed to do 
what we asked.

[[Page 364]]

    (e) If we are unable to find you. If there is a question about 
whether you continue to be disabled by blindness and we are unable to 
find you to resolve the question, we will find that your disability, has 
ended. The month it ends will be the first month in which the question 
arose and we could not find you.
    (f) Before we stop your benefits. Before we stop your benefits or 
period of disability, we will give you a chance to give us your reasons 
why we should not stop your benefits or your period of disability. 
Section 404.1595 describes your rights and the procedures we will 
follow.
    (g) If you are in an appropriate vocational rehabilitation program. 
(1) Your benefits, and those of your dependents, may be continued for 
months after November 1980 after your impairment is no longer disabling 
if--
    (i) Your disability did not end before December 1980;
    (ii) You are participating in an appropriate program of vocational 
rehabilitation, that is, one that has been approved under a State plan 
approved under title I of the Rehabilitation Act of 1973 and which meets 
the requirements outlined in 34 CFR part 361 for a rehabilitation 
program;
    (iii) You began the program before your disability ended; and
    (iv) We have determined that your completion of the program, or your 
continuation in the program for a specified period of time, will 
significantly increase the likelihood that you will not have to return 
to the disability benefit rolls.
    (2) Your benefits generally will be stopped with the month--
    (i) You complete the program;
    (ii) You stop participating in the program for any reason; or
    (iii) We determine that your continuing participation in the program 
will no longer significantly increase the likelihood that you will be 
permanently removed from the disability benefit rolls.

Exception: In no case will your benefits be stopped with a month earlier 
than the second month after your disability ends.

[45 FR 55584, Aug. 20, 1980, as amended at 47 FR 31543, July 21, 1982; 
47 FR 52693, Nov. 23, 1982; 49 FR 22272, May 29, 1984; 50 FR 50130, Dec. 
6, 1985; 51 FR 17617, May 14, 1986; 59 FR 1635, Jan. 12, 1994]



Sec. 404.1587  Circumstances under which we may suspend your benefits before we make a determination.

    We will suspend your benefits if all of the information we have 
clearly shows that you are not disabled and we will be unable to 
complete a determination soon enough to prevent us from paying you more 
monthly benefits than you are entitled to. This may occur when you are 
blind as defined in the law and age 55 or older and you have returned to 
work similar to work you previously performed.

                    Continuing or Stopping Disability



Sec. 404.1588  Your responsibility to tell us of events that may change your disability status.

    If you are entitled to cash benefits or to a period of disability 
because you are disabled, you should promptly tell us if--
    (a) Your condition improves;
    (b) You return to work;
    (c) You increase the amount of your work; or
    (d) Your earnings increase.



Sec. 404.1589  We may conduct a review to find out whether you continue to be disabled.

    After we find that you are disabled, we must evaluate your 
impairment(s) from time to time to determine if you are still eligible 
for disability cash benefits. We call this evaluation a continuing 
disability review. We may begin a continuing disability review for any 
number of reasons including your failure to follow the provisions of the 
Social Security Act or these regulations. When we begin such a review, 
we will notify you that we are reviewing your eligibility for disability 
benefits, why we are reviewing your eligibility, that in medical reviews 
the medical improvement review standard will apply, that our review 
could result in the termination of your benefits, and

[[Page 365]]

that you have the right to submit medical and other evidence for our 
consideration during the continuing disability review. In doing a 
medical review, we will develop a complete medical history of at least 
the preceding 12 months in any case in which a determination is made 
that you are no longer under a disability. If this review shows that we 
should stop payment of your benefits, we will notify you in writing and 
give you an opportunity to appeal. In Sec. 404.1590 we describe those 
events that may prompt us to review whether you continue to be disabled.

[51 FR 16825, May 7, 1986]



Sec. 404.1590  When and how often we will conduct a continuing disability review.

    (a) General. We conduct continuing disability reviews to determine 
whether or not you continue to meet the disability requirements of the 
law. Payment of cash benefits or a period of disability ends if the 
medical or other evidence shows that you are not disabled as determined 
under the standards set out in section 223(f) of the Social Security 
Act.
    (b) When we will conduct a continuing disability review. A 
continuing disability review will be started if--
    (1) You have been scheduled for a medical improvement expected diary 
review;
    (2) You have been scheduled for a periodic review (medical 
improvement possible or medical improvement not expected) in accordance 
with the provisions of paragraph (d) of this section;
    (3) We need a current medical or other report to see if your 
disability continues. (This could happen when, for example, an advance 
in medical technology, such as improved treatment for Alzheimer's 
disease or a change in vocational therapy or technology raises a 
disability issue.);
    (4) You return to work and successfully complete a period of trial 
work;
    (5) Substantial earnings are reported to your wage record;
    (6) You tell us that you have recovered from your disability or that 
you have returned to work;
    (7) Your State Vocational Rehabilitation Agency tells us that--
    (i) The services have been completed; or
    (ii) You are now working; or
    (iii) You are able to work;
    (8) Someone in a position to know of your physical or mental 
condition tells us that you are not disabled, that you are not following 
prescribed treatment, that you have returned to work, or that you are 
failing to follow the provisions of the Social Security Act or these 
regulations, and it appears that the report could be substantially 
correct;
    (9) Evidence we receive raises a question as to whether your 
disability continues; or
    (10) You have been scheduled for a vocational reexamination diary 
review.
    (c) Definitions. As used in this section--
    Medical improvement expected diary--refers to a case which is 
scheduled for review at a later date because the individual's 
impairment(s) is expected to improve. Generally, the diary period is set 
for not less than 6 months or for not more than 18 months. Examples of 
cases likely to be scheduled for medical improvement expected diary are 
fractures and cases in which corrective surgery is planned and recovery 
can be anticipated.
    Permanent impairment--medical improvement not expected--refers to a 
case in which any medical improvement in the person's impairment(s) is 
not expected. This means an extremely severe condition determined on the 
basis of our experience in administering the disability programs to be 
at least static, but more likely to be progressively disabling either by 
itself or by reason of impairment complications, and unlikely to improve 
so as to permit the individual to engage in substantial gainful 
activity. The interaction of the individual's age, impairment 
consequences and lack of recent attachment to the labor market may also 
be considered in determining whether an impairment is permanent. 
Improvement which is considered temporary under Sec. 404.1579(c)(4) or 
Sec. 404.1594(c)(3)(iv), as appropriate, will not be considered in 
deciding if an impairment is permanent. Examples of permanent 
impairments taken from the list contained in our other written

[[Page 366]]

guidelines which are available for public review are as follows and are 
not intended to be all inclusive:
    (1) Parkinsonian Syndrome which has reached the level of severity 
necessary to meet the Listing in appendix 1.
    (2) Amyotrophic Lateral Sclerosis which has reached the level of 
severity necessary to meet the Listing in appendix 1.
    (3) Diffuse pulmonary fibrosis in an individual age 55 or over which 
has reached the level of severity necessary to meet the Listing in 
appendix 1.
    (4) Amputation of leg at hip.
    Nonpermanent impairment--refers to a case in which any medical 
improvement in the person's impairment(s) is possible. This means an 
impairment for which improvement cannot be predicted based on current 
experience and the facts of the particular case but which is not at the 
level of severity of an impairment that is considered permanent. 
Examples of nonpermanent impairments are: regional enteritis, 
hyperthyroidism, and chronic ulcerative colitis.
    Vocational reexamination diary--refers to a case which is scheduled 
for review at a later date because the individual is undergoing 
vocational therapy, training or an educational program which may improve 
his or her ability to work so that the disability requirement of the law 
is no longer met. Generally, the diary period will be set for the length 
of the training, therapy, or program of education.
    (d) Frequency of review. If your impairment is expected to improve, 
generally we will review your continuing eligibility for disability 
benefits at intervals from 6 months to 18 months following our most 
recent decision. Our notice to you about the review of your case will 
tell you more precisely when the review will be conducted. If your 
disability is not considered permanent but is such that any medical 
improvement in your impairment(s) cannot be accurately predicted, we 
will review your continuing eligibility for disability benefits at least 
once every 3 years. If your disability is considered permanent, we will 
review your continuing eligibility for benefits no less frequently than 
once every 7 years but no more frequently than once every 5 years. 
Regardless of your classification, we will conduct an immediate 
continuing disability review if a question of continuing disability is 
raised pursuant to paragraph (b) of this section.
    (e) Change in classification of impairment. If the evidence 
developed during a continuing disability review demonstrates that your 
impairment has improved, is expected to improve, or has worsened since 
the last review, we may reclassify your impairment to reflect this 
change in severity. A change in the classification of your impairment 
will change the frequency with which we will review your case. We may 
also reclassify certain impairments because of improved tests, 
treatment, and other technical advances concerning those impairments.
    (f) Review after administrative appeal. If you were found eligible 
to receive or to continue to receive disability benefits on the basis of 
a decision by an administrative law judge, the Appeals Council or a 
Federal court, we will not conduct a continuing disability review 
earlier than 3 years after that decision unless your case should be 
scheduled for a medical improvement expected or vocational reexamination 
diary review or a question of continuing disability is raised pursuant 
to paragraph (b) of this section.
    (g) Waiver of timeframes. All cases involving a nonpermanent 
impairment will be reviewed by us at least once every 3 years unless we, 
after consultation with the State agency, determine that the requirement 
should be waived to ensure that only the appropriate number of cases are 
reviewed. The appropriate number of cases to be reviewed is to be based 
on such considerations as the backlog of pending reviews, the projected 
number of new applications, and projected staffing levels. Such waiver 
shall be given only after good faith effort on the part of the State to 
meet staffing requirements and to process the reviews on a timely basis. 
Availability of independent medical resources may also be a factor. A 
waiver in this context refers to our administrative discretion to 
determine the appropriate number of cases to be reviewed on a State by

[[Page 367]]

State basis. Therefore, your continuing disability review may be delayed 
longer than 3 years following our original decision or other review 
under certain circumstances. Such a delay would be based on our need to 
ensure that backlogs, reviews required to be performed by the Social 
Security Disability Benefits Reform Act of 1984 (Pub. L. 98-460), and 
new disability claims workloads are accomplished within available 
medical and other resources in the State agency and that such reviews 
are done carefully and accurately.

[51 FR 16825, May 7, 1986]



Sec. 404.1591  If your medical recovery was expected and you returned to work.

    If your impairment was expected to improve and you returned to full-
time work with no significant medical limitations and acknowledge that 
medical improvement has occurred, we may find that your disability ended 
in the month you returned to work. Unless there is evidence showing that 
your disability has not ended, we will use the medical and other 
evidence already in your file and the fact that you returned to full-
time work without significant limitations to determine that you are no 
longer disabled. (If your impairment is not expected to improve, we will 
not ordinarily review your claim until the end of the trial work period, 
as described in Sec. 404.1592.)

    Example: Evidence obtained during the processing of your claim 
showed that you had an impairment that was expected to improve about 18 
months after your disability began. We, therefore, told you that your 
claim would be reviewed again at that time. However, before the time 
arrived for your scheduled medical re-examination, you told us that you 
had returned to work and your impairment had improved. We investigated 
immediately and found that, in the 16th month after your disability 
began, you returned to full-time work without any significant medical 
restrictions. Therefore, we would find that your disability ended in the 
first month you returned to full-time work.

[50 FR 50130, Dec. 6, 1985]



Sec. 404.1592  The trial work period.

    (a) Definition of the trial work period. The trial work period is a 
period during which you may test your ability to work and still be 
considered disabled. It begins and ends as described in paragraph (e) of 
this section. During this period, you may perform services (see 
paragraph (b) of this section) in as many as 9 months, but these months 
do not have to be consecutive. We will not consider those services as 
showing that your disability has ended until you have performed services 
in at least 9 months. However, after the trial work period has ended we 
will consider the work you did during the trial work period in 
determining whether your disability ended at any time after the trial 
work period.
    (b) What we mean by services. When used in this section, services 
means any activity, even though it is not substantial gainful activity, 
which is done by a person in employment or self-employment for pay or 
profit, or is the kind normally done for pay or profit. If you are an 
employee, we will consider your work to be services if in any calendar 
year after 1989 you earn more than $200 a month ($75 a month is the 
amount for calendar years 1979 through 1989, and $50 a month is the 
amount for calendar years before 1979). If you are self-employed, we 
will consider your activities services if in any calendar year after 
1989, your net earnings are more than $200 a month ($75 a month is the 
amount for calendar years 1979 through 1989, and $50 a month is the 
amount for calendar years before 1979), or you work more than 40 hours a 
month in the business in any calendar year after 1989 (15 hours a month 
is the figure for calendar years before 1990). We generally do not 
consider work to be services when it is done without remuneration or 
merely as therapy or training, or when it is work usually done in a 
daily routine around the house, or in self-care.
    (c) Limitations on the number of trial work periods. You may have 
only one trial work period during a period of entitlement to cash 
benefits.
    (d) Who is and is not entitled to a trial work period. (1) Those who 
are receiving disability insurance benefits, child's benefits based on 
disability and, beginning December 1, 1980, those who are receiving 
widows' or widowers' benefits

[[Page 368]]

based on disability, or surviving divorced spouses' benefits based on 
disability, generally are entitled to a trial work period.
    (2) You are not entitled to a trial work period if--
    (i) You are entitled to a period of disability but not to disability 
insurance cash benefits; or
    (ii) You are receiving disability insurance benefits in a second 
period of disability for which you did not have to complete a waiting 
period.
    (e) When the trial work period begins and ends. The trial work 
period begins with the month in which you become entitled to disability 
insurance cash benefits, to child's cash benefits based on disability or 
to widow's, widower's, or surviving divorced spouse's cash benefits 
based on disability. It cannot begin before the month in which you file 
your application for benefits and for widows, widowers, and surviving 
divorced spouses, it cannot begin before December 1, 1980. It ends with 
the close of whichever of the following calendar months is the earlier:
    (1) The 9th month (whether or not the months have been consecutive) 
in which you have performed services; or
    (2) The month in which new evidence, other than evidence relating to 
any work you did during the trial work period, shows that you are not 
disabled, even though you have not worked a full 9 months. We may find 
that your disability has ended at any time during the trial work period 
if the medical or other evidence shows that you are no longer disabled 
(see Sec. 404.1594).

[45 FR 55584, Aug. 20, 1980, as amended at 49 FR 22273, May 29, 1984; 50 
FR 50130, Dec. 6, 1985; 54 FR 53605, Dec. 29, 1989]



Sec. 404.1592a  The reentitlement period.

    (a) General. The reentitlement period is an additional period after 
9 months of trial work during which you may continue to test your 
ability to work if you have a disabling impairment. You will not be paid 
benefits for any month, after the third month, in this period in which 
you do substantial gainful activity and you will be paid benefits for 
months in which you do not do substantial gainful activity. (See 
Secs. 404.316, 404.337, 404.352 and 404.401a.) If anyone else is 
receiving monthly benefits based on your earnings record, that 
individual will not be paid benefits for any month for which you cannot 
be paid benefits during the reentitlement period. If your benefits are 
stopped because you do substantial gainful activity they may be started 
again without a new application and a new determination of disability if 
you discontinue doing substantial gainful activity during this period. 
In determining, for reentitlement benefit purposes, whether you do 
substantial gainful activity in a month, we consider only your work in 
or earnings for that month; we do not consider the average amount of 
your work or earnings over a period of months.
    (b) When the reentitlement period begins and ends. The reentitlement 
period begins with the first month following completion of 9 months of 
trial work but cannot begin earlier than December 1, 1980. It ends with 
whichever is earlier--
    (1) The month before the first month in which your impairment no 
longer exists or is not medically disabling; or
    (2) The last day of the 15th month following the end of your trial 
work period. (See Secs. 404.316, 404.337, and 404.352 for when your 
benefits end.)
    (c) When you are not entitled to a reentitlement period. You are not 
entitled to a reentitlement period if:
    (1) You are entitled to a period of disability, but not to 
disability insurance cash benefits;
    (2) You are not entitled to a trial work period;
    (3) Your entitlement to disability insurance benefits ended before 
you completed 9 months of trial work in that period of disability.

[49 FR 22273, May 29, 1984, as amended at 58 FR 64883, Dec. 10, 1993]



Sec. 404.1593  Medical evidence in continuing disability review cases.

    (a) General. If you are entitled to benefits or if a period of 
disability has been established for you because you are disabled, we 
will have your case file with the supporting medical evidence previously 
used to establish or continue your entitlement. Generally, therefore, 
the medical evidence we will need for a continuing disability review 
will be that required to make a current

[[Page 369]]

determination or decision as to whether you are still disabled, as 
defined under the medical improvement review standard. See 
Secs. 404.1579 and 404.1594.
    (b) Obtaining evidence from your medical sources. You must provide 
us with reports from your physician, psychologist, or others who have 
treated or evaluated you, as well as any other evidence that will help 
us determine if you are still disabled. See Sec. 404.1512. You must have 
a good reason for not giving us this information or we may find that 
your disability has ended. See Sec. 404.1594(e)(2). If we ask you, you 
must contact your medical sources to help us get the medical reports. We 
will make every reasonable effort to help you in getting medical reports 
when you give us permission to request them from your physician, 
psychologist, or other medical sources. See Sec. 404.1512(d)(1) 
concerning what we mean by every reasonable effort. In some instances, 
such as when a source is known to be unable to provide certain tests or 
procedures or is known to be nonproductive or uncooperative, we may 
order a consultative examination while awaiting receipt of medical 
source evidence. Before deciding that your disability has ended, we will 
develop a complete medical history covering at least the 12 months 
preceding the date you sign a report about your continuing disability 
status. See Sec. 404.1512(c).
    (c) When we will purchase a consultative examination. A consultative 
examination may be purchased when we need additional evidence to 
determine whether or not your disability continues. As a result, we may 
ask you, upon our request and reasonable notice, to undergo consultative 
examinations and tests to help us determine if you are still disabled. 
See Sec. 404.1517. We will decide whether or not to purchase a 
consultative examination in accordance with the standards in 
Secs. 404.1519a through 404.1519b.

[56 FR 36962, Aug. 1, 1991]



Sec. 404.1594  How we will determine whether your disability continues or ends.

    (a) General. There is a statutory requirement that, if you are 
entitled to disability benefits, your continued entitlement to such 
benefits must be reviewed periodically. If you are entitled to 
disability benefits as a disabled worker or as a person disabled since 
childhood, or, for monthly benefits payable for months after December 
1990, as a disabled widow, widower, or surviving divorced spouse, there 
are a number of factors we consider in deciding whether your disability 
continues. We must determine if there has been any medical improvement 
in your impairment(s) and, if so, whether this medical improvement is 
related to your ability to work. If your impairment(s) has not medically 
improved we must consider whether one or more of the exceptions to 
medical improvement applies. If medical improvement related to your 
ability to work has not occurred and no exception applies, your benefits 
will continue. Even where medical improvement related to your ability to 
work has occurred or an exception applies, in most cases (see paragraph 
(e) of this section for exceptions), we must also show that you are 
currently able to engage in substantial gainful activity before we can 
find that you are no longer disabled.
    (b) Terms and definitions. There are several terms and definitions 
which are important to know in order to understand how we review whether 
your disability continues.
    (1) Medical improvement. Medical improvement is any decrease in the 
medical severity of your impairment(s) which was present at the time of 
the most recent favorable medical decision that you were disabled or 
continued to be disabled. A determination that there has been a decrease 
in medical severity must be based on changes (improvement) in the 
symptoms, signs and/or laboratory findings associated with your 
impairment(s) (see Sec. 404.1528).

    Example 1: You were awarded disability benefits due to a herniated 
nucleus pulposus. At the time of our prior decision granting you 
benefits you had had a laminectomy. Postoperatively, a myelogram still 
shows evidence of a persistent deficit in your lumbar spine. You had 
pain in your back, and pain and a burning sensation in your right foot 
and leg. There were no muscle weakness or neurological changes and a 
modest decrease in motion in your back and leg. When we reviewed your 
claim your treating physician reported that he had seen you regularly

[[Page 370]]

every 2 to 3 months for the past 2 years. No further myelograms had been 
done, complaints of pain in the back and right leg continued especially 
on sitting or standing for more than a short period of time. Your doctor 
further reported a moderately decreased range of motion in your back and 
right leg, but again no muscle atrophy or neurological changes were 
reported. Medical improvement has not occurred because there has been no 
decrease in the severity of your back impairment as shown by changes in 
symptoms, signs or laboratory findings.
    Example 2: You were awarded disability benefits due to rheumatoid 
arthritis. At the time, laboratory findings were positive for this 
condition. Your doctor reported persistent swelling and tenderness of 
your fingers and wrists and that you complained of joint pain. Current 
medical evidence shows that while laboratory tests are still positive 
for rheumatoid arthritis, your impairment has responded favorably to 
therapy so that for the last year your fingers and wrists have not been 
significantly swollen or painful. Medical improvement has occurred 
because there has been a decrease in the severity of your impairment as 
documented by the current symptoms and signs reported by your physician. 
Although your impairment is subject to temporary remission and 
exacerbations, the improvement that has occurred has been sustained long 
enough to permit a finding of medical improvement. We would then 
determine if this medical improvement is related to your ability to 
work.

    (2) Medical improvement not related to ability to do work. Medical 
improvement is not related to your ability to work if there has been a 
decrease in the severity of the impairment(s) as defined in paragraph 
(b)(1) of this section, present at the time of the most recent favorable 
medical decision, but no increase in your functional capacity to do 
basic work activities as defined in paragraph (b)(4) of this section. If 
there has been any medical improvement in your impairment(s), but it is 
not related to your ability to do work and none of the exceptions 
applies, your benefits will be continued.

    Example: You are 65 inches tall and weighed 246 pounds at the time 
your disability was established. You had venous insufficiency and 
persistent edema in your legs. At the time, your ability to do basic 
work activities was affected because you were able to sit for 6 hours, 
but were able to stand or walk only occasionally. At the time of our 
continuing disability review, you had undergone a vein stripping 
operation. You now weigh 220 pounds and have intermittent edema. You are 
still able to sit for 6 hours at a time and to stand or walk only 
occasionally although you report less discomfort on walking. Medical 
improvement has occurred because there has been a decrease in the 
severity of the existing impairment as shown by your weight loss and the 
improvement in your edema. This medical improvement is not related to 
your ability to work, however, because your functional capacity to do 
basic work activities (i.e., the ability to sit, stand and walk) has not 
increased.

    (3) Medical improvement that is related to ability to do work. 
Medical improvement is related to your ability to work if there has been 
a decrease in the severity, as defined in paragraph (b)(1) of this 
section, of the impairment(s) present at the time of the most recent 
favorable medical decision and an increase in your functional capacity 
to do basic work activities as discussed in paragraph (b)(4) of this 
section. A determination that medical improvement related to your 
ability to do work has occurred does not, necessarily, mean that your 
disability will be found to have ended unless it is also shown that you 
are currently able to engage in substantial gainful activity as 
discussed in paragraph (b)(5) of this section.

    Example 1: You have a back impairment and had a laminectomy to 
relieve the nerve root impingement and weakness in your left leg. At the 
time of our prior decision, basic work activities were affected because 
you were able to stand less than 6 hours, and sit no more than \1/2\ 
hour at a time. You had a successful fusion operation on your back about 
1 year before our review of your entitlement. At the time of our review, 
the weakness in your leg has decreased. Your functional capacity to 
perform basic work activities now is unimpaired because you now have no 
limitation on your ability to sit, walk, or stand. Medical improvement 
has occurred because there has been a decrease in the severity of your 
impairment as demonstrated by the decreased weakness in your leg. This 
medical improvement is related to your ability to work because there has 
also been an increase in your functional capacity to perform basic work 
activities (or residual functional capacity) as shown by the absence of 
limitation on your ability to sit, walk, or stand. Whether or not your 
disability is found to have ended, however, will depend on our 
determination as to whether you can currently engage in substantial 
gainful activity.
    Example 2: You were injured in an automobile accident receiving a 
compound fracture to your right femur and a fractured pelvis. When you 
applied for disability benefits

[[Page 371]]

10 months after the accident your doctor reported that neither fracture 
had yet achieved solid union based on his clinical examination. X-rays 
supported this finding. Your doctor estimated that solid union and a 
subsequent return to full weight bearing would not occur for at least 3 
more months. At the time of our review 6 months later, solid union had 
occurred and you had been returned to full weight-bearing for over a 
month. Your doctor reported this and the fact that your prior fractures 
no longer placed any limitation on your ability to walk, stand, lift, 
etc., and, that in fact, you could return to fulltime work if you so 
desired.
    Medical improvement has occurred because there has been a decrease 
in the severity of your impairments as shown by X-ray and clinical 
evidence of solid union and your return to full weight-bearing. This 
medical improvement is related to your ability to work because you no 
longer meet the same listed impairment in appendix 1 of this subpart 
(see paragraph (c)(3)(i) of this section). In fact, you no longer have 
an impairment which is severe (see Sec. 404.1521) and your disability 
will be found to have ended.

    (4) Functional capacity to do basic work activities. Under the law, 
disability is defined, in part, as the inability to do any substantial 
gainful activity by reason of any medically determinable physical or 
mental impairment(s). In determining whether you are disabled under the 
law, we must measure, therefore, how and to what extent your 
impairment(s) has affected your ability to do work. We do this by 
looking at how your functional capacity for doing basic work activities 
has been affected. Basic work activities means the abilities and 
aptitudes necessary to do most jobs. Included are exertional abilities 
such as walking, standing, pushing, pulling, reaching and carrying, and 
nonexertional abilities and aptitudes such as seeing, hearing, speaking, 
remembering, using judgment, dealing with changes and dealing with both 
supervisors and fellow workers. A person who has no impairment(s) would 
be able to do all basic work activities at normal levels; he or she 
would have an unlimited functional capacity to do basic work activities. 
Depending on its nature and severity, an impairment will result in some 
limitation to the functional capacity to do one or more of these basic 
work activities. Diabetes, for example, can result in circulatory 
problems which could limit the length of time a person could stand or 
walk and damage to his or her eyes as well, so that the person also had 
limited vision. What a person can still do despite an impairment, is 
called his or her residual functional capacity. How the residual 
functional capacity is assessed is discussed in more detail in 
Sec. 404.1545. Unless an impairment is so severe that it is deemed to 
prevent you from doing substantial gainful activity (see Secs. 404.1525 
and 404.1526), it is this residual functional capacity that is used to 
determine whether you can still do your past work or, in conjunction 
with your age, education and work experience, any other work.
    (i) A decrease in the severity of an impairment as measured by 
changes (improvement) in symptoms, signs or laboratory findings can, if 
great enough, result in an increase in the functional capacity to do 
work activities. Vascular surgery (e.g., femoropopliteal bypass) may 
sometimes reduce the severity of the circulatory complications of 
diabetes so that better circulation results and the person can stand or 
walk for longer periods. When new evidence showing a change in signs, 
symptoms and laboratory findings establishes that both medical 
improvement has occurred and your functional capacity to perform basic 
work activities, or residual functional capacity, has increased, we say 
that medical improvement which is related to your ability to do work has 
occurred. A residual functional capacity assessment is also used to 
determine whether you can engage in substantial gainful activity and, 
thus, whether you continue to be disabled (see paragraph (b)(5) of this 
section).
    (ii) Many impairment-related factors must be considered in assessing 
your functional capacity for basic work activities. Age is one key 
factor. Medical literature shows that there is a gradual decrease in 
organ function with age; that major losses and deficits become 
irreversible over time and that maximum exercise performance diminishes 
with age. Other changes related to sustained periods of inactivity and 
the aging process include muscle atrophy, degenerative joint changes, 
decrease in range of motion, and changes in the

[[Page 372]]

cardiac and respiratory systems which limit the exertional range.
    (iii) Studies have also shown that the longer an individual is away 
from the workplace and is inactive, the more difficult it becomes to 
return to ongoing gainful employment. In addition, a gradual change 
occurs in most jobs so that after about 15 years, it is no longer 
realistic to expect that skills and abilities acquired in these jobs 
will continue to apply to the current workplace. Thus, if you are age 50 
or over and have been receiving disability benefits for a considerable 
period of time, we will consider this factor along with your age in 
assessing your residual functional capacity. This will ensure that the 
disadvantages resulting from inactivity and the aging process during a 
long period of disability will be considered. In some instances where 
available evidence does not resolve what you can or cannot do on a 
sustained basis, we will provide special work evaluations or other 
appropriate testing.
    (5) Ability to engage in substantial gainful activity. In most 
instances, we must show that you are able to engage in substantial 
gainful activity before your benefits are stopped. When doing this, we 
will consider all your current impairments not just that impairment(s) 
present at the time of the most recent favorable determination. If we 
cannot determine that you are still disabled based on medical 
considerations alone (as discussed in Secs. 404.1525 and 404.1526), we 
will use the new symptoms, signs and laboratory findings to make an 
objective assessment of your functional capacity to do basic work 
activities or residual functional capacity and we will consider your 
vocational factors. See Secs. 404.1545 through 404.1569.
    (6) Evidence and basis for our decision. Our decisions under this 
section will be made on a neutral basis without any initial inference as 
to the presence or absence of disability being drawn from the fact that 
you have previously been determined to be disabled. We will consider all 
evidence you submit, as well as all evidence we obtain from your 
treating physician(s) and other medical or nonmedical sources. What 
constitutes evidence and our procedures for obtaining it are set out in 
Secs. 404.1512 through 404.1518. Our determination regarding whether 
your disability continues will be made on the basis of the weight of the 
evidence.
    (7) Point of comparison. For purposes of determining whether medical 
improvement has occurred, we will compare the current medical severity 
of that impairment(s) which was present at the time of the most recent 
favorable medical decision that you were disabled or continued to be 
disabled to the medical severity of that impairment(s) at that time. If 
medical improvement has occurred, we will compare your current 
functional capacity to do basic work activities (i.e., your residual 
functional capacity) based on this previously existing impairment(s) 
with your prior residual functional capacity in order to determine 
whether the medical improvement is related to your ability to do work. 
The most recent favorable medical decision is the latest decision 
involving a consideration of the medical evidence and the issue of 
whether you were disabled or continued to be disabled which became 
final.
    (c) Determining medical improvement and its relationship to your 
abilities to do work. Paragraphs (b) (1) through (3) of this section 
discuss what we mean by medical improvement, medical improvement not 
related to your ability to work and medical improvement that is related 
to your ability to work. How we will arrive at the decision that medical 
improvement has occurred and its relationship to the ability to do work, 
is discussed below.
    (1) Medical improvement. Medical improvement is any decrease in the 
medical severity of impairment(s) present at the time of the most recent 
favorable medical decision that you were disabled or continued to be 
disabled and is determined by a comparison of prior and current medical 
evidence which must show that there have been changes (improvement) in 
the symptoms, signs or laboratory findings associated with that 
impairment(s).
    (2) Determining if medical improvement is related to ability to 
work. If there is a decrease in medical severity as shown by the 
symptoms, signs and laboratory findings, we then must determine if it

[[Page 373]]

is related to your ability to do work. In paragraph (b)(4) of this 
section, we explain the relationship between medical severity and 
limitation on functional capacity to do basic work activities (or 
residual functional capacity) and how changes in medical severity can 
affect your residual functional capacity. In determining whether medical 
improvement that has occurred is related to your ability to do work, we 
will assess your residual functional capacity (in accordance with 
paragraph (b)(4) of this section) based on the current severity of the 
impairment(s) which was present at your last favorable medical decision. 
Your new residual functional capacity will then be compared to your 
residual functional capacity at the time of our most recent favorable 
medical decision. Unless an increase in the current residual functional 
capacity is based on changes in the signs, symptoms, or laboratory 
findings, any medical improvement that has occurred will not be 
considered to be related to your ability to do work.
    (3) Following are some additional factors and considerations which 
we will apply in making these determinations.
    (i) Previous impairment met or equaled listings. If our most recent 
favorable decision was based on the fact that your impairment(s) at the 
time met or equaled the severity contemplated by the Listing of 
Impairments in appendix 1 of this subpart, an assessment of your 
residual functional capacity would not have been made. If medical 
improvement has occurred and the severity of the prior impairment(s) no 
longer meets or equals the same listing section used to make our most 
recent favorable decision, we will find that the medical improvement was 
related to your ability to work. Appendix 1 of this subpart describes 
impairments which, if severe enough, affect a person's ability to work. 
If the appendix level of severity is met or equaled, the individual is 
deemed, in the absence of evidence to the contrary, to be unable to 
engage in substantial gainful activity. If there has been medical 
improvement to the degree that the requirement of the listing section is 
no longer met or equaled, then the medical improvement is related to 
your ability to work. We must, of course, also establish that you can 
currently engage in gainful activity before finding that your disability 
has ended.
    (ii) Prior residual functional capacity assessment made. The 
residual functional capacity assessment used in making the most recent 
favorable medical decision will be compared to the residual functional 
capacity assessment based on current evidence in order to determine if 
your functional capacity for basic work activities has increased. There 
will be no attempt made to reassess the prior residual functional 
capacity.
    (iii) Prior residual functional capacity assessment should have been 
made, but was not. If the most recent favorable medical decision should 
have contained an assessment of your residual functional capacity (i.e., 
your impairments did not meet or equal the level of severity 
contemplated by the Listing of Impairments in appendix 1 of this 
subpart) but does not, either because this assessment is missing from 
your file or because it was not done, we will reconstruct the residual 
functional capacity. This reconstructed residual functional capacity 
will accurately and objectively assess your functional capacity to do 
basic work activities. We will assign the maximum functional capacity 
consistent with an allowance.

    Example: You were previously found to be disabled on the basis that 
``while your impairment did not meet or equal a listing, it did prevent 
you from doing your past or any other work.'' The prior adjudicator did 
not, however, include a residual functional capacity assessment in the 
rationale of this decision and a review of the prior evidence does not 
show that such an assessment was ever made. If a decrease in medical 
severity, i.e., medical improvement, has occurred, the residual 
functional capacity based on the current level of severity of your 
impairment will have to be compared with your residual functional 
capacity based on its prior severity in order to determine if the 
medical improvement is related to your ability to do work. In order to 
make this comparison, we will review the prior evidence and make an 
objective assessment of your residual functional capacity at the time of 
our most recent favorable medical determination, based on the symptoms, 
signs and laboratory findings as they then existed.

    (iv) Impairment subject to temporary remission. In some cases the 
evidence shows that an individual's impairments are subject to temporary 
remission. In

[[Page 374]]

assessing whether medical improvement has occurred in persons with this 
type of impairment, we will be careful to consider the longitudinal 
history of the impairments, including the occurrence of prior remission, 
and prospects for future worsenings. Improvement in such impairments 
that is only temporary will not warrant a finding of medical 
improvement.
    (v) Prior file cannot be located. If the prior file cannot be 
located, we will first determine whether you are able to now engage in 
substantial gainful activity based on all your current impairments. (In 
this way, we will be able to determine that your disability continues at 
the earliest point without addressing the often lengthy process of 
reconstructing prior evidence.) If you cannot engage in substantial 
gainful activity currently, your benefits will continue unless one of 
the second group of exceptions applies (see paragraph (e) of this 
section). If you are able to engage in substantial gainful activity, we 
will determine whether an attempt should be made to reconstruct those 
portions of the missing file that were relevant to our most recent 
favorable medical decision (e.g., work history, medical evidence from 
treating sources and the results of consultative examinations). This 
determination will consider the potential availability of old records in 
light of their age, whether the source of the evidence is still in 
operation; and whether reconstruction efforts will yield a complete 
record of the basis for the most recent favorable medical decision. If 
relevant parts of the prior record are not reconstructed either because 
it is determined not to attempt reconstruction or because such efforts 
fail, medical improvement cannot be found. The documentation of your 
current impairments will provide a basis for any future reviews. If the 
missing file is later found, it may serve as a basis for reopening any 
decision under this section in accordance with the rules in 
Sec. 404.988.
    (d) First group of exceptions to medical improvement. The law 
provides for certain limited situations when your disability can be 
found to have ended even though medical improvement has not occurred, if 
you can engage in substantial gainful activity. These exceptions to 
medical improvement are intended to provide a way of finding that a 
person is no longer disabled in those limited situations where, even 
though there has been no decrease in severity of the impairment(s), 
evidence shows that the person should no longer be considered disabled 
or never should have been considered disabled. If one of these 
exceptions applies, we must also show that, taking all your current 
impairment(s) into account, not just those that existed at the time of 
our most recent favorable medical decision, you are now able to engage 
in substantial gainful activity before your disability can be found to 
have ended. As part of the review process, you will be asked about any 
medical or vocational therapy you received or are receiving. Your 
answers and the evidence gathered as a result as well as all other 
evidence, will serve as the basis for the finding that an exception 
applies.
    (1) Substantial evidence shows that you are the beneficiary of 
advances in medical or vocational therapy or technology (related to your 
ability to work). Advances in medical or vocational therapy or 
technology are improvements in treatment or rehabilitative methods which 
have increased your ability to do basic work activities. We will apply 
this exception when substantial evidence shows that you have been the 
beneficiary of services which reflect these advances and they have 
favorably affected the severity of your impairment or your ability to do 
basic work activities. This decision will be based on new medical 
evidence and a new residual functional capacity assessment. (See 
Sec. 404.1545.) In many instances, an advanced medical therapy or 
technology will result in a decrease in severity as shown by symptoms, 
signs and laboratory findings which will meet the definition of medical 
improvement. This exception will, therefore, see very limited 
application.
    (2) Substantial evidence shows that you have undergone vocational 
therapy (related to your ability to work). Vocational therapy (related 
to your ability to work) may include, but is not limited to, additional 
education, training, or work experience that improves your ability to 
meet the vocational requirements of more jobs. This decision will

[[Page 375]]

be based on substantial evidence which includes new medical evidence and 
a new residual functional capacity assessment. (See Sec. 404.1545.) If, 
at the time of our review you have not completed vocational therapy 
which could affect the continuance of your disability, we will review 
your claim upon completion of the therapy.

    Example 1: You were found to be disabled because the limitations 
imposed on you by your impairment allowed you to only do work that was 
at a sedentary level of exertion. Your prior work experience was work 
that required a medium level of exertion. Your age and education at the 
time would not have qualified you for work that was below this medium 
level of exertion. You enrolled in and completed a specialized training 
course which qualifies you for a job in data processing as a computer 
programmer in the period since you were awarded benefits. On review of 
your claim, current evidence shows that there is no medical improvement 
and that you can still do only sedentary work. As the work of a computer 
programmer is sedentary in nature, you are now able to engage in 
substantial gainful activity when your new skills are considered.
    Example 2: You were previously entitled to benefits because the 
medical evidence and assessment of your residual functional capacity 
showed you could only do light work. Your prior work was considered to 
be heavy in nature and your age, education and the nature of your prior 
work qualified you for work which was no less than medium in exertion. 
The current evidence and residual functional capacity show there has 
been no medical improvement and that you can still do only light work. 
Since you were originally entitled to benefits, your vocational 
rehabilitation agency enrolled you in and you successfully completed a 
trade school course so that you are now qualified to do small appliance 
repair. This work is light in nature, so when your new skills are 
considered, you are now able to engage in substantial gainful activity 
even though there has been no change in your residual functional 
capacity.

    (3) Substantial evidence shows that based on new or improved 
diagnostic or evaluative techniques your impairment(s) is not as 
disabling as it was considered to be at the time of the most recent 
favorable decision. Changing methodologies and advances in medical and 
other diagnostic or evaluative techniques have given, and will continue 
to give, rise to improved methods for measuring and documenting the 
effect of various impairments on the ability to do work. Where, by such 
new or improved methods, substantial evidence shows that your 
impairment(s) is not as severe as was determined at the time of our most 
recent favorable medical decision, such evidence may serve as a basis 
for finding that you are no longer disabled, if you can currently engage 
in substantial gainful activity. In order to be used under this 
exception, however, the new or improved techniques must have become 
generally available after the date of our most recent favorable medical 
decision.
    (i) How we will determine which methods are new or improved 
techniques and when they become generally available. New or improved 
diagnostic techniques or evaluations will come to our attention by 
several methods. In reviewing cases, we often become aware of new 
techniques when their results are presented as evidence. Such techniques 
and evaluations are also discussed and acknowledged in medical 
literature by medical professional groups and other governmental 
entities. Through these sources, we develop listings of new techniques 
and when they become generally available. For example, we will consult 
the Health Care Financing Administration for its experience regarding 
when a technique is recognized for payment under Medicare and when they 
began paying for the technique.
    (ii) How you will know which methods are new or improved techniques 
and when they become generally available.We will let you know which 
methods we consider to be new or improved techniques and when they 
become available through two vehicles.
    (A) Some of the future changes in the Listing of Impairments in 
appendix 1 of this subpart will be based on new or improved diagnostic 
or evaluative techniques. Such listings changes will clearly state this 
fact as they are published as Notices of Proposed Rulemaking and the new 
or improved technique will be considered generally available as of the 
date of the final publication of that particular listing in the Federal 
Register.
    (B) A cumulative list since 1970 of new or improved diagnostic 
techniques or evaluations, how they changed the

[[Page 376]]

evaluation of the applicable impairment and the month and year they 
became generally available, will be published in the Notices section of 
the Federal Register. Included will be any changes in the Listing of 
Impairments published in the Code of Federal Regulations since 1970 
which are reflective of new or improved techniques. No cases will be 
processed under this exception until this cumulative listing is so 
published. Subsequent changes to the list will be published 
periodically. The period will be determined by the volume of changes 
needed.

    Example: The electrocardiographic exercise test has replaced the 
Master's 2-step test as a measurement of heart function since the time 
of your last favorable medical decision. Current evidence could show 
that your condition, which was previously evaluated based on the 
Master's 2-step test, is not now as disabling as was previously thought. 
If, taking all your current impairments into account, you are now able 
to engage in substantial gainful activity, this exception would be used 
to find that you are no longer disabled even if medical improvement has 
not occurred.

    (4) Substantial evidence demonstrates that any prior disability 
decision was in error. We will apply the exception to medical 
improvement based on error if substantial evidence (which may be 
evidence on the record at the time any prior determination of the 
entitlement to benefits based on disability was made, or newly obtained 
evidence which relates to that determination) demonstrates that a prior 
determination was in error. A prior determination will be found in error 
only if:
    (i) Substantial evidence shows on its face that the decision in 
question should not have been made (e.g., the evidence in your file such 
as pulmonary function study values was misread or an adjudicative 
standard such as a listing in appendix 1 or a medical/vocational rule in 
appendix 2 of this subpart was misapplied).

    Example 1: You were granted benefits when it was determined that 
your epilepsy met Listing 11.02. This listing calls for a finding of 
major motor seizures more frequently than once a month as documented by 
EEG evidence and by a detailed description of a typical seizure pattern. 
A history of either diurnal episodes or nocturnal episodes with 
residuals interfering with daily activities is also required. On review, 
it is found that a history of the frequency of your seizures showed that 
they occurred only once or twice a year. The prior decision would be 
found to be in error, and whether you were still considered to be 
disabled would be based on whether you could currently engage in 
substantial gainful activity.
    Example 2: Your prior award of benefits was based on vocational rule 
201.12 in appendix 2 of this subpart. This rule applies to a person age 
50-54 who has at least a high school education, whose previous work was 
entirely at a semiskilled level, and who can do only sedentary work. On 
review, it is found that at the time of the prior determination you were 
actually only age 46 and vocational rule 201.21 should have been used. 
This rule would have called for a denial of your claim and the prior 
decision is found to have been in error. Continuation of your disability 
would depend on a finding of your current ability to engage in 
substantial gainful activity.

    (ii) At the time of the prior evaluation, required and material 
evidence of the severity of your impairment(s) was missing. That 
evidence becomes available upon review, and substantial evidence 
demonstrates that had such evidence been present at the time of the 
prior determination, disability would not have been found.

    Example: You were found disabled on the basis of chronic obstructive 
pulmonary disease. The severity of your impairment was documented 
primarily by pulmonary function testing results. The evidence showed 
that you could do only light work. Spirometric tracings of this testing, 
although required, were not obtained, however. On review, the original 
report is resubmitted by the consultative examining physician along with 
the corresponding spirometric tracings. A review of the tracings shows 
that the test was invalid. Current pulmonary function testing supported 
by spirometric tracings reveals that your impairment does not limit your 
ability to perform basic work activities in any way. Error is found 
based on the fact that required, material evidence which was originally 
missing now becomes available and shows that if it had been available at 
the time of the prior determination, disability would not have been 
found.

    (iii) Substantial evidence which is new evidence which relates to 
the prior determination (of allowance or continuance) refutes the 
conclusions that were based upon the prior evidence (e.g., a tumor 
thought to be malignant was later shown to have actually been benign). 
Substantial evidence must show that had the new evidence (which relates 
to the prior determination) been considered at the time of the prior 
decision, the claim would not have

[[Page 377]]

been allowed or continued. A substitution of current judgment for that 
used in the prior favorable decision will not be the basis for applying 
this exception.

    Example: You were previously found entitled to benefits on the basis 
of diabetes mellitus which the prior adjudicator believed was equivalent 
to the level of severity contemplated in the Listing of Impairments. The 
prior record shows that you had ``brittle'' diabetes for which you were 
taking insulin. Your urine was 3+ for sugar, and you alleged occasional 
hypoglycemic attacks caused by exertion. On review, symptoms, signs and 
laboratory findings are unchanged. The current adjudicator feels, 
however, that your impairment clearly does not equal the severity 
contemplated by the listings. Error cannot be found because it would 
represent a substitution of current judgment for that of the prior 
adjudicator that your impairment equaled a listing.

    (iv) The exception for error will not be applied retroactively under 
the conditions set out above unless the conditions for reopening the 
prior decision (see Sec. 404.988) are met.
    (5) You are currently engaging in substantial gainful activity. If 
you are currently engaging in substantial gainful activity before we 
determine whether you are no longer disabled because of your work 
activity, we will consider whether you are entitled to a trial work 
period as set out in Sec. 404.1592. We will find that your disability 
has ended in the month in which you demonstrated your ability to engage 
in substantial gainful activity (following completion of a trial work 
period, where it applies). This exception does not apply in determining 
whether you continue to have a disabling impairment(s) (Sec. 404.1511) 
for purposes of deciding your eligibility for a reentitlement period 
(Sec. 404.1592a).
    (e) Second group of exceptions to medical improvement. In addition 
to the first group of exceptions to medical improvement, the following 
exceptions may result in a determination that you are no longer 
disabled. In these situations the decision will be made without a 
determination that you have medically improved or can engage in 
substantial gainful activity.
    (1) A prior determination or decision was fraudulently obtained. If 
we find that any prior favorable determination or decision was obtained 
by fraud, we may find that you are not disabled. In addition, we may 
reopen your claim under the rules in Sec. 404.988. In determining 
whether a prior favorable determination or decision was fraudulently 
obtained, we will take into account any physical, mental, educational, 
or linguistic limitations (including any lack of facility with the 
English language) which you may have had at the time.
    (2) You do not cooperate with us. If there is a question about 
whether you continue to be disabled and we ask you to give us medical or 
other evidence or to go for a physical or mental examination by a 
certain date, we will find that your disability has ended if you fail, 
without good cause, to do what we ask. Section 404.911 explains the 
factors we consider and how we will determine generally whether you have 
good cause for failure to cooperate. In addition, Sec. 404.1518 
discusses how we determine whether you have good cause for failing to 
attend a consultative examination. The month in which your disability 
ends will be the first month in which you failed to do what we asked.
    (3) We are unable to find you. If there is a question about whether 
you continue to be disabled and we are unable to find you to resolve the 
question, we will determine that your disability has ended. The month 
your disability ends will be the first month in which the question arose 
and we could not find you.
    (4) You fail to follow prescribed treatment which would be expected 
to restore your ability to engage in substantial gainful activity. If 
treatment has been prescribed for you which would be expected to restore 
your ability to work, you must follow that treatment in order to be paid 
benefits. If you are not following that treatment and you do not have 
good cause for failing to follow that treatment, we will find that your 
disability has ended (see Sec. 404.1530(c)). The month your disability 
ends will be the first month in which you failed to follow the 
prescribed treatment.
    (f) Evaluation steps. To assure that disability reviews are carried 
out in a uniform manner, that decisions of continuing disability can be 
made in the most expeditious and administratively

[[Page 378]]

efficient way, and that any decisions to stop disability benefits are 
made objectively, neutrally and are fully documented, we will follow 
specific steps in reviewing the question of whether your disability 
continues. Our review may cease and benefits may be continued at any 
point if we determine there is sufficient evidence to find that you are 
still unable to engage in substantial gainful activity. The steps are:
    (1) Are you engaging in substantial gainful activity? If you are 
(and any applicable trial work period has been completed), we will find 
disability to have ended (see paragraph (d)(5) of this section).
    (2) If you are not, do you have an impairment or combination of 
impairments which meets or equals the severity of an impairment listed 
in appendix 1 of this subpart? If you do, your disability will be found 
to continue.
    (3) If you do not, has there been medical improvement as defined in 
paragraph (b)(1) of this section? If there has been medical improvement 
as shown by a decrease in medical severity, see step (4). If there has 
been no decrease in medical severity, there has been no medical 
improvement. (See step (5).)
    (4) If there has been medical improvement, we must determine whether 
it is related to your ability to do work in accordance with paragraphs 
(b)(1) through (4) of this section; i.e., whether or not there has been 
an increase in the residual functional capacity based on the 
impairment(s) that was present at the time of the most recent favorable 
medical determination. If medical improvement is not related to your 
ability to do work, see step (5). If medical improvement is related to 
your ability to do work, see step (6).
    (5) If we found at step (3) that there has been no medical 
improvement or if we found at step (4) that the medical improvement is 
not related to your ability to work, we consider whether any of the 
exceptions in paragraphs (d) and (e) of this section apply. If none of 
them apply, your disability will be found to continue. If one of the 
first group of exceptions to medical improvement applies, see step (6). 
If an exception from the second group of exceptions to medical 
improvement applies, your disability will be found to have ended. The 
second group of exceptions to medical improvement may be considered at 
any point in this process.
    (6) If medical improvement is shown to be related to your ability to 
do work or if one of the first group of exceptions to medical 
improvement applies, we will determine whether all your current 
impairments in combination are severe (see Sec. 404.1521). This 
determination will consider all your current impairments and the impact 
of the combination of those impairments on your ability to function. If 
the residual functional capacity assessment in step (4) above shows 
significant limitation of your ability to do basic work activities, see 
step (7). When the evidence shows that all your current impairments in 
combination do not significantly limit your physical or mental abilities 
to do basic work activities, these impairments will not be considered 
severe in nature. If so, you will no longer be considered to be 
disabled.
    (7) If your impairment(s) is severe, we will assess your current 
ability to engage in substantial gainful activity in accordance with 
Sec. 404.1561. That is we will assess your residual functional capacity 
based on all your current impairments and consider whether you can still 
do work you have done in the past. If you can do such work, disability 
will be found to have ended.
    (8) If you are not able to do work you have done in the past, we 
will consider one final step. Given the residual functional capacity 
assessment and considering your age, education and past work experience, 
can you do other work? If you can, disability will be found to have 
ended. If you cannot, disability will be found to continue.
    (g) The month in which we will find you are no longer disabled. If 
the evidence shows that you are no longer disabled, we will find that 
your disability ended in the earliest of the following months.
    (1) The month the evidence shows you are no longer disabled under 
the rules set out in this section, and you were disabled only for a 
specified period of time in the past;
    (2) The month the evidence shows you are no longer disabled under 
the rules set out in this section, but not earlier than the month in 
which we

[[Page 379]]

mail you a notice saying that the information we have shows that you are 
not disabled;
    (3) The month in which you demonstrated your ability to engage in 
substantial gainful activity (following completion of a trial work 
period); however, we may pay you benefits for certain months in and 
after the reentitlement period which follows the trial work period. (See 
Sec. 404.1592a for a discussion of the reentitlement period. If you are 
receiving benefits on your own earnings record, see Sec. 404.316 for 
when your benefits will end. See Sec. 404.352 if you are receiving 
benefits on a parent's earnings as a disabled adult child.);
    (4) The month in which you actually do substantial gainful activity 
(where you are not entitled to a trial work period);
    (5) The month in which you return to full-time work, with no 
significant medical restrictions and acknowledge that medical 
improvement has occurred, and we expected your impairment(s) to improve 
(see Sec. 404.1591);
    (6) The first month in which you failed without good cause to do 
what we asked, when the rule set out in paragraph (e)(2) of this section 
applies;
    (7) The first month in which the question of continuing disability 
arose and we could not find you, when the rule set out in paragraph 
(e)(3) of this section applies;
    (8) The first month in which you failed without good cause to follow 
prescribed treatment, when the rule set out in paragraph (e)(4) of this 
section applies; or
    (9) The first month you were told by your physician that you could 
return to work provided there is no substantial conflict between your 
physician's and your statements regarding your awareness of your 
capacity for work and the earlier date is supported by the medical 
evidence.
    (h) Before we stop your benefits. Before we stop your benefits or a 
period of disability, we will give you a chance to explain why we should 
not do so. Sections 404.1595 and 404.1597 describe your rights 
(including appeal rights) and the procedures we will follow.

[50 FR 50130, Dec. 6, 1985; 51 FR 7063, Feb. 28, 1986; 51 FR 16015, Apr. 
30, 1986, as amended at 52 FR 44971, Nov. 24, 1987; 57 FR 30121, July 8, 
1992; 59 FR 1635, Jan. 12, 1994]



Sec. 404.1595  When we determine that you are not now disabled.

    (a) When we will give you advance notice. Except in those 
circumstances described in paragraph (d) of this section, we will give 
you advance notice when we have determined that you are not now disabled 
because the information we have conflicts with what you have told us 
about your disability. If your dependents are receiving benefits on your 
Social Security number and do not live with you, we will also give them 
advance notice. To give you advance notice, we will contact you by mail, 
telephone or in person.
    (b) What the advance notice will tell you. We will give you a 
summary of the information we have. We will also tell you why we have 
determined that you are not now disabled, and will give you a chance to 
reply. If it is because of--
    (1) Medical reasons. The advance notice will tell you what the 
medical information in your file shows;
    (2) Your work activity. The advance notice will tell you what 
information we have about the work you are doing or have done, and why 
this work shows that you are not disabled; or
    (3) Your failure to give us information we need or do what we ask. 
The advance notice will tell you what information we need and why we 
need it or what you have to do and why.
    (c) What you should do if you receive an advance notice. If you 
agree with the advance notice, you do not need to take any action. If 
you desire further information or disagree with what we have told you, 
you should immediately write or telephone the State agency or the social 
security office that gave you the advance notice or you may visit any 
social security office. If you believe you are now disabled, you should 
tell us why. You may give us any additional or new information, 
including reports from your doctors, hospitals, employers or others, 
that you believe we should have. You should send these as soon as 
possible to the local social

[[Page 380]]

security office or to the office that gave you the advance notice. We 
consider 10 days to be enough time for you to tell us, although we will 
allow you more time if you need it. You will have to ask for additional 
time beyond 10 days if you need it.
    (d) When we will not give you advance notice. We will not give you 
advance notice when we determine that you are not disabled if--
    (1) We recently told you that the information we have shows that you 
are not now disabled, that we were gathering more information, and that 
your benefits will stop; or
    (2) We are stopping your benefits because you told us you are not 
now disabled; or
    (3) We recently told you that continuing your benefits would 
probably cause us to overpay you and you asked us to stop your benefits.



Sec. 404.1596  Circumstances under which we may suspend your benefits before we make a determination.

    (a) General. Under some circumstances, we may stop your benefits 
before we make a determination. Generally, we do this when the 
information we have clearly shows you are not now disabled but we cannot 
determine when your disability ended. These situations are described in 
paragraph (b)(1) and other reasons are given in paragraph (b)(2) of this 
section. We refer to this as a suspension of benefits. Your benefits, as 
well as those of your dependents (regardless of where they receive their 
benefits), may be suspended. When we do this we will give you advance 
notice. (See Sec. 404.1595.) We will contact your spouse and children if 
they are receiving benefits on your Social Security number, and the 
benefits are being mailed to an address different from your own.
    (b) When we will suspend your benefits--(1) You are not now 
disabled. We will suspend your benefits if the information we have 
clearly shows that you are not disabled and we will be unable to 
complete a determination soon enough to prevent us from paying you more 
monthly benefits than you are entitled to. This may occur when--
    (i) New medical or other information clearly shows that you are able 
to do substantial gainful activity and your benefits should have stopped 
more than 2 months ago;
    (ii) You completed a 9-month period of trial work more than 2 months 
ago and you are still working;
    (iii) At the time you filed for benefits your condition was expected 
to improve and you were expected to be able to return to work. You 
subsequently did return to work more than 2 months ago with no 
significant medical restrictions; or
    (iv) You are not entitled to a trial work period and you are 
working.
    (2) Other reasons. We will also suspend your benefits if--
    (i) You have failed to respond to our request for additional medical 
or other evidence and we are satisfied that you received our request and 
our records show that you should be able to respond.
    (ii) We are unable to locate you and your checks have been returned 
by the Post Office as undeliverable; or
    (iii) You refuse to accept vocational rehabilitation services 
without a good reason. Section 404.422 gives you examples of good 
reasons for refusing to accept vocational rehabilitation services.
    (c) When we will not suspend your cash benefits. We will not suspend 
your cash benefits if--
    (1) The evidence in your file does not clearly show that you are not 
disabled;
    (2) We have asked you to furnish additional information;
    (3) You have become disabled by another impairment; or
    (4) After November 1980, even though your impairment is no longer 
disabling,
    (i) You are participating in an appropriate vocational 
rehabilitation program (that is, one that has been approved under a 
State plan approved under title I of the Rehabilitation Act of 1973 and 
which meets the requirements outlined in 34 CFR part 361) which you 
began during your disability,
    (ii) Your disability did not end before December 1, 1980, and
    (iii) We have determined that your completion of the program, or 
your continuation in the program for a specified period of time, will 
significantly increase the likelihood that you will

[[Page 381]]

not have to return to the disability benefit rolls.

[45 FR 55584, Aug. 20, 1980, as amended at 47 FR 31543, July 21, 1982; 
47 FR 52693, Nov. 23, 1982; 51 FR 17617, May 14, 1986]



Sec. 404.1597  After we make a determination that you are not now disabled.

    (a) General. If we determine that you do not meet the disability 
requirements of the law, your benefits generally will stop. We will send 
you a formal written notice telling you why we believe you are not 
disabled and when your benefits should stop. If your spouse and children 
are receiving benefits on your Social Security number, we will also stop 
their benefits and tell them why. The notices will explain your right to 
reconsideration if you disagree with our determination. However, your 
benefits may continue after November 1980 even though your impairment is 
no longer disabling, if your disability did not end before December 
1980, and you are particpating in an appropriate vocational 
rehabilitation program as described in Sec. 404.1596 which you began 
before your disability ended. In addition, we must have determined that 
your completion of the program, or your continuation in the program for 
a specified period of time, will significantly increase the likelihood 
that you will not have to return to the disability benefit rolls. You 
may still appeal our determination that you are not disabled even though 
your benefits are continuing because of your participation in an 
appropriate vocational rehabilitation program. You may also appeal a 
determination that your completion or of continuation for a specified 
period of time in an appropriate vocational rehabilitation program will 
not significantly increase the likelihood that you will not have to 
return to the disability benefit rolls and, therefore, you are not 
entitled to continue to receive benefits.
    (b) If we make a determination that your physical or mental 
impairment(s) has ceased, did not exist, or is no longer disabling 
(Medical Cessation Determination). If we make a determination that the 
physical or mental impairment(s) on the basis of which benefits were 
payable has ceased, did not exist, or is no longer disabling (a medical 
cessation determination), your benefits will stop. As described in 
paragraph (a) of this section, you will receive a written notice 
explaining this determination and the month your benefits will stop. The 
written notice will also explain your right to appeal if you disagree 
with our determination and your right to request that your benefits and 
the benefits, if any, of your spouse or children, be continued under 
Sec. 404.1597a. For the purpose of this section, benefits means 
disability cash payments and/or Medicare, if applicable. The continued 
benefit provisions of this section do not apply to an initial 
determination on an application for disability benefits, or to a 
determination that you were disabled only for a specified period of 
time.

[47 FR 31544, July 21, 1982, as amended at 51 FR 17618, May 14, 1986; 53 
FR 29020, Aug. 2, 1988; 53 FR 39015, Oct. 4, 1988]



Sec. 404.1597a  Continued benefits pending appeal of a medical cessation determination.

    (a) General. If we determine that you are not entitled to benefits 
because the physical or mental impairment(s) on the basis of which such 
benefits were payable is found to have ceased, not to have existed, or 
to no longer be disabling, and you appeal that determination, you may 
choose to have your benefits continued pending reconsideration and/or a 
hearing before an administrative law judge on the disability cessation 
determination. For the purpose of this entire section, the election of 
continued benefits means the election of disability cash payments and/or 
Medicare, if applicable. You can also choose to have the benefits 
continued for anyone else receiving benefits based on your wages and 
self-employment income (and anyone else receiving benefits because of 
your entitlement to benefits based on disability). If you appeal a 
medical cessation under both title II and title XVI (a concurrent case), 
the title II claim will be handled in accordance with title II 
regulations while the title XVI claim will be handled in accordance with 
the title XVI regulations.
    (b) When the provisions of this section are available. (1) Benefits 
may be continued under this section only if the

[[Page 382]]

determination that your physical or mental impairment(s) has ceased, has 
never existed, or is no longer disabling is made on or after January 12, 
1983 (or before January 12, 1983, and a timely request for 
reconsideration or a hearing before an administrative law judge is 
pending on that date).
    (2) Benefits may be continued under this section only for months 
beginning with January 1983, or the first month for which benefits are 
no longer otherwise payable following our determination that your 
physical or mental impairment(s) has ceased, has never existed, or is no 
longer disabling, whichever is later.
    (3) Continued payment of benefits under this section will stop 
effective with the earlier of:
    (i) The month before the month in which an administrative law 
judge's hearing decision finds that your physical or mental 
impairment(s) has ceased, has never existed, or is no longer disabling 
or the month before the month of a new administrative law judge decision 
(or final action by the Appeals Council on the administrative law 
judge's recommended decision) if your case was sent back to an 
administrative law judge for further action; or
    (ii) The month before the month no timely request for a 
reconsideration or a hearing before an administrative law judge is 
pending. These continued benefits may be stopped or adjusted because of 
certain events (such as work and earnings or receipt of worker's 
compensation) which occur while you are receiving these continued 
benefits and affect your right to receive continued benefits.

These continued benefits may be stopped or adjusted because of certain 
events (such as work and earning or receipt of worker's compensation) 
which occur while you are receiving these continued benefits and affect 
your right to receive continued benefits.

    (c) Continuation of benefits for anyone else pending your appeal. 
(1) When you file a request for reconsideration or hearing before an 
administrative law judge on our determination that your physical or 
mental impairment(s) has ceased, has never existed, or is no longer 
disabling, or your case has been sent back (remanded) to an 
administrative law judge for further action, you may also choose to have 
benefits continue for anyone else who is receiving benefits based on 
your wages and self-employment income (and for anyone else receiving 
benefits because of your entitlement to benefits based on disability), 
pending the outcome of your appeal.
    (2) If anyone else is receiving benefits based on your wages and 
self-employment income, we will notify him or her of the right to choose 
to have his or her benefits continue pending the outcome of your appeal. 
Such benefits can be continued for the time period in paragraph (b) of 
this section only if he or she chooses to have benefits continued and 
you also choose to have his or her benefits continued.
    (d) Statement of choice. When you or another party request 
reconsideration under Sec. 404.908(a) or a hearing before an 
administrative law judge under Sec. 404.932(a) on our determination that 
your physical or mental impairment(s) has ceased, has never existed, or 
is no longer disabling, or if your case is sent back (remanded) to an 
administrative law judge for further action, we will explain your right 
to receive continued benefits and ask you to complete a statement 
specifying which benefits you wish to have continued pending the outcome 
of the reconsideration or hearing before an administrative law judge. 
You may elect to receive only Medicare benefits during appeal even if 
you do not want to receive continued disability benefits. If anyone else 
is receiving benefits based on your wages and self-employment income (or 
because of your entitlement to benefits based on disability), we will 
ask you to complete a statement specifying which benefits you wish to 
have continued for them, pending the outcome of the request for 
reconsideration or hearing before an administrative law judge. If you 
request appeal but you do not want to receive continued benefits, we 
will ask you to complete a statement declining continued benefits 
indicating that you do not want to have your benefits and those of your 
family, if any, continued during the appeal.

[[Page 383]]

    (e) Your spouse's or children's statement of choice. If you request, 
in accordance with paragraph (d) of this section, that benefits also be 
continued for anyone who had been receiving benefits based on your wages 
and self-employment, we will send them a written notice. The notice will 
explain their rights and ask them to complete a statement either 
declining continued benefits, or specifying which benefits they wish to 
have continued, pending the outcome of the request for reconsideration 
or a hearing before an administrative law judge.
    (f) What you must do to receive continued benefits pending notice of 
our reconsideration determination. (1) If you want to receive continued 
benefits pending the outcome of your request for reconsideration, you 
must request reconsideration and continuation of benefits no later than 
10 days after the date you receive the notice of our initial 
determination that your physical or mental impairment(s) has ceased, has 
never existed, or is no longer disabling. Reconsideration must be 
requested as provided in Sec. 404.909, and you must request continued 
benefits using a statement in accordance with paragraph (d) of this 
section.
    (2) If you fail to request reconsideration and continued benefits 
within the 10-day period required by paragraph (f)(1) of this section, 
but later ask that we continue your benefits pending a reconsidered 
determination, we will use the rules in Sec. 404.911 to determine 
whether good cause exists for your failing to request benefit 
continuation within 10 days after receipt of the notice of the initial 
cessation determination. If you request continued benefits after the 10-
day period, we will consider the request to be timely and will pay 
continued benefits only if good cause for delay is established.
    (g) What you must do to receive continued benefits pending an 
administrative law judge's decision. (1) To receive continued benefits 
pending an administrative law judge's decision on our reconsideration 
determination, you must request a hearing and continuation of benefits 
no later than 10 days after the date you receive the notice of our 
reconsideration determination that your physical or mental impairment(s) 
has ceased, has never existed, or is no longer disabling. A hearing must 
be requested as provided in Sec. 404.933, and you must request continued 
benefits using a statement in accordance with paragraph (d) of this 
section.
    (2) If you request continued benefits pending an administrative law 
judge's decision but did not request continued benefits while we were 
reconsidering the initial cessation determination, your benefits will 
begin effective the month of the reconsideration determination.
    (3) If you fail to request continued payment of benefits within the 
10-day period required by paragraph (g)(1) of this section, but you 
later ask that we continue your benefits pending an administrative law 
judge's decision on our reconsidered determination, we will use the 
rules as provided in Sec. 404.911 to determine whether good cause exists 
for your failing to request benefit continuation within 10 days after 
receipt of the reconsideration determination. If you request continued 
benefits after the 10-day period, we will consider the request to be 
timely and will pay continued benefits only if good cause for delay is 
established.
    (h) What anyone else must do to receive continued benefits pending 
our reconsideration determination or an administrative law judge's 
decision. (1) When you or another party (see Secs. 404.908(a) and 
404.932(a)) request a reconsideration or a hearing before an 
administrative law judge on our medical cessation determination or when 
your case is sent back (remanded) to an administrative law judge for 
further action, you may choose to have benefits continue for anyone else 
who is receiving benefits based on your wages and self-employment 
income. An eligible individual must also choose whether or not to have 
his or her benefits continue pending your appeal by completing a 
separate statement of election as described in paragraph (e) of this 
section.
    (2) He or she must request continuation of benefits no later than 10 
days after the date he or she receives notice of termination of 
benefits. He or she will then receive continued benefits beginning with 
the later of January 1983, or the first month for which benefits

[[Page 384]]

are no longer otherwise payable following our initial or reconsideration 
determination that your physical or mental impairment(s) has ceased, has 
never existed, or is no longer disabling. Continued benefits will 
continue until the earlier of:
    (i) The month before the month in which an administrative law 
judge's hearing decision finds that your physical or mental 
impairment(s) has ceased, has never existed, or is no longer disabling 
or the month before the month of the new administrative law judge 
decision (or final action is taken by the Appeals Council on the 
administrative law judge's recommended decision) if your case was sent 
back to an administrative law judge for further action; or
    (ii) The month before the month no timely request for a 
reconsideration or a hearing before an administrative law judge is 
pending. These continued benefits may be stopped or adjusted because of 
certain events (such as work and earnings or payment of worker's 
compensation) which occur while an eligible individual is receiving 
continued benefits and affect his or her right to receive continued 
benefits.

These continued benefits may be stopped or adjusted because of certain 
events (such as work and earnings or payment of workers compensation) 
which occur while an eligible individual is receiving continued benefits 
and affect his or her right to receive continued benefits.

    (3) If he or she fails to request continuation of benefits within 
the 10-day period required by this paragraph, but requests continuation 
of benefits at a later date, we will use the rules as provided in 
Sec. 404.911 to determine whether good cause exists for his or her 
failure to request continuation of benefits within 10 days after receipt 
of the notice of termination of his or her benefits. His or her late 
request will be considered to be timely and we will pay him or her 
continued benefits only if good cause for delay is established.
    (4) If you choose not to have benefits continued for anyone else who 
is receiving benefits based on your wages and self-employment income, 
pending the appeal on our determination, we will not continue benefits 
to him or her.
    (i) What you must do when your case is remanded to an administrative 
law judge. If we send back (remand) your case to an administrative law 
judge for further action under the rules provided in Sec. 404.977, and 
the administrative law judge's decision or dismissal order issued on 
your medical cessation appeal is vacated and is no longer in effect, 
continued benefits are payable pending a new decision by the 
administrative law judge or final action is taken by the Appeals Council 
on the administrative law judge's recommended decision.
    (1) If you (and anyone else receiving benefits based on your wages 
and self-employment income or because of your disability) previously 
elected to receive continued benefits pending the administrative law 
judge's decision, we will automatically start these same continued 
benefits again. We will send you a notice telling you this, and that you 
do not have to do anything to have these same benefits continued until 
the month before the month the new decision of order of dismissal is 
issued by the administrative law judge or until the month before the 
month the Appeals Council takes final action on the administrative law 
judge's recommended decision. These benefits will begin again with the 
first month of nonpayment based on the prior administrative law judge 
hearing decision or dismissal order. Our notice explaining reinstatement 
of continued benefits will also tell you to report to us any changes or 
events that affect your receipt of benefits.
    (2) After we automatically reinstate your continued benefits as 
described in paragraph (h)(1) of this section, we will contact you to 
determine if any adjustment is required to the amount of continued 
benefits payable due to events that affect the right to receive benefits 
involving you, your spouse and/or children. If you have returned to 
work, we will request additional information about this work activity. 
If you are working, your continued benefits will not be stopped while 
your appeal of the medical cessation of disability is still pending 
unless you have completed a trial work period and are engaging in 
substantial gainful activity. In this

[[Page 385]]

event, we will suspend your continued benefits. If any other changes 
have occurred which would require a reduction in benefit amounts, or 
nonpayment of benefits, we will send an advance notice to advise of any 
adverse change before the adjustment action is taken. The notice will 
also advise you of the right to explain why these benefits should not be 
adjusted or stopped. You will also receive a written notice of our 
determination. The notice will also explain your right to 
reconsideration if you disagree with this determination.
    (3) If the final decision on your appeal of your medical cessation 
is a favorable one, we will send you a written notice in which we will 
advise you of your right to benefits, if any, before you engaged in 
substantial gainful activity and to reentitlement should you stop 
performing substantial gainful activity. If you disagree with our 
determination, you will have the right to appeal this decision.
    (4) If the final decision on your appeal of your medical cessation 
is an unfavorable one (the cessation is affirmed), you will also be sent 
a written notice advising you of our determination, and your right to 
appeal if you think we are wrong.
    (5) If you (or the others receiving benefits based on your wages and 
self-employment income or because of your disability) did not previously 
elect to have benefits continued pending an administrative law judge 
decision, and you now want to elect continued benefits, you must request 
to do so no later than 10 days after you receive our notice telling you 
about continued benefits. If you fail to request continued benefits 
within the 10-day period required by paragraph (f)(1) of this section, 
but later ask that we continue your benefits pending an administrative 
law judge remand decision, we will use the rules in Sec. 404.911 to 
determine whether good cause exists for your failing to request benefit 
continuation within 10 days after receipt of the notice telling you 
about benefit continuation. We will consider the request to be timely 
and will pay continued benefits only if good cause for delay is 
established. If you make this new election, benefits may begin with the 
month of the order sending (remanding) your case back to the 
administrative law judge. Before we begin to pay you continued benefits 
as described in paragraph (h)(1) of this section we will contact you to 
determine if any adjustment is required to the amount of continued 
benefits payable due to events which may affect your right to benefits. 
If you have returned to work, we will request additional information 
about this work activity. If you are working, continued benefits may be 
started and will not be stopped because of your work while your appeal 
of the medical cessation of your disability is still pending unless you 
have completed a trial work period and are engaging in substantial 
gainful activity. If any changes have occurred which establish a basis 
for not paying continued benefits or a reduction in benefit amount, we 
will send you a notice explaining the adjustment or the reason why we 
cannot pay continued benefits. The notice will also explain your right 
to reconsideration if you disagree with this determination. If the final 
decision on your appeal of your medical cessation is a favorable one, we 
will send you a written notice in which we will advise you of your right 
to benefits, if any, before you engaged in substantial gainful activity 
and to reentitlement should you stop performing substantial gainful 
activity. If you disagree with our determination, you will have the 
right to appeal this decision. If the final decision on your appeal of 
your medical cessation is an unfavorable one (the cessation is 
affirmed), you will also be sent a written notice advising you of our 
determination, and your right to appeal if you think we are wrong.
    (6) If a court orders that your case be sent back to us (remanded) 
and your case is sent to an administrative law judge for further action 
under the rules provided in Sec. 404.983, the administrative law judge's 
decision or dismissal order on your medical cessation appeal is vacated 
and is no longer in effect. Continued benefits are payable to you and 
anyone else receiving benefits based on your wages and self-employment 
income or because of your disability pending a new decision by the 
administrative law judge or final action is taken by the Appeals Council 
on the

[[Page 386]]

administrative law judge's recommended decision. In these court-remanded 
cases reaching the administrative law judge, we will follow the same 
rules provided in paragraphs (i) (1), (2), (3), (4) and (5) of this 
section.
    (j) Responsibility to pay back continued benefits. (1) If the final 
decision of the Secretary affirms the determination that you are not 
entitled to benefits, you will be asked to pay back any continued 
benefits you receive. However, as described in the overpayment recovery 
and waiver provisions of subpart F of this part, you will have the right 
to ask that you not be required to pay back the benefits. You will not 
be asked to pay back any Medicare benefits you received during the 
appeal.
    (2) Anyone else receiving benefits based on your wages and self-
employment income (or because of your disability) will be asked to pay 
back any continued benefits he or she received if the determination that 
your physical or mental impairment(s) has ceased, has never existed, or 
is no longer disabling, is not changed by the final decision of the 
Secretary. However, he or she will have the right to ask that he or she 
not be required to pay them back, as described in the overpayment 
recovery and waiver provisions of subpart F of this part. He or she will 
not be asked to pay back any Medicare benefits he or she received during 
the appeal.
    (3) Waiver of recovery of an overpayment resulting from the 
continued benefits paid to you or anyone else receiving benefits based 
on your wages and self-employment income (or because of your disability) 
may be considered as long as the determination was appealed in good 
faith. It will be assumed that such appeal is made in good faith and, 
therefore, any overpaid individual has the right to waiver consideration 
unless such individual fails to cooperate in connection with the appeal, 
e.g., if the individual fails (without good reason) to give us medical 
or other evidence we request, or to go for a physical or mental 
examination when requested by us, in connection with the appeal. In 
determining whether an individual has good cause for failure to 
cooperate and, thus, whether an appeal was made in good faith, we will 
take into account any physical, mental, educational, or linguistic 
limitations (including any lack of facility with the English language) 
the individual may have which may have caused the individual's failure 
to cooperate.

[53 FR 29020, Aug. 2, 1988; 53 FR 39015, Oct. 4, 1988, as amended at 57 
FR 1383, Jan. 14, 1992; 59 FR 1635, Jan. 12, 1994]



Sec. 404.1598  If you become disabled by another impairment(s).

    If a new severe impairment(s) begins in or before the month in which 
your last impairment(s) ends, we will find that your disability is 
continuing. The new impairment(s) need not be expected to last 12 months 
or to result in death, but it must be severe enough to keep you from 
doing substantial gainful activity, or severe enough so that you are 
still disabled under Sec. 404.1594.

[50 FR 50136, Dec. 6, 1985]



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.

[[Page 389]]

    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

[[Page 390]]

    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.)

[[Page 391]]

    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

[[Page 392]]

    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.                                                               


[[Page 393]]

[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

[[Page 394]]

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
------------------------------------------------------------------------


    Or

    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
------------------------------------------------------------------------


    Or

    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
------------------------------------------------------------------------


    Or

    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;

Or

    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.);

Or


[[Page 400]]


    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 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;

Or

    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;

Or

    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;

Or

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

Or

    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

[[Page 402]]

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

[[Page 403]]

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'' 
(thallium201) 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:

[[Page 415]]

    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

[[Page 416]]

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

[[Page 417]]

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

[[Page 418]]

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

[[Page 419]]

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;

or

    4. Emotional withdrawal and/or isolation;

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);

OR

    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:

[[Page 420]]

    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;

or

    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;

OR

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

OR

    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;

OR

    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;

or

    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

[[Page 421]]

    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

    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 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);

OR

    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.

[[Page 422]]

    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:

[[Page 423]]

    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

[[Page 424]]

    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

[[Page 425]]

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

[[Page 426]]

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.

[[Page 427]]

    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.

[[Page 428]]

    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.

or

    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.

or

    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:

[[Page 429]]

    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.

or

    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.

or

    C. Generalized scleroderma with digital contractures.

or

    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.

or

    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.

or

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

or

    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.

or

    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.

or

    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.

or

    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.

or

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

[[Page 430]]

    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.

or

    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.

or

    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.

or

    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.

or

    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.

or

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

or

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

or

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

or

    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.

or

    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

[[Page 431]]

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

[[Page 432]]

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.

[[Page 433]]

    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

[[Page 434]]

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 
------------------------------------------------------------------------


Or

    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
------------------------------------------------------------------------


Or

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

Or

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

Or

    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;

Or

    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;

Or

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

Or

    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;

Or

    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 inpatient hospitalization for 
longer than 24 hours for control of asthma counts as two attacks, and an 
evaluation period of at

[[Page 436]]

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

Or

    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;

Or

    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.);

Or

    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;

Or

    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 treatment;

Or

    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;

Or

    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 m2 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./1.73m2/ 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

[[Page 442]]

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.

[[Page 443]]

    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.

[[Page 444]]

    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

[[Page 445]]

    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.

[[Page 446]]

    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.

[[Page 447]]

    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

[[Page 448]]

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.

[[Page 449]]

    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

[[Page 450]]

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

[[Page 451]]

    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

[[Page 452]]

    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;

OR

    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;

OR

    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. 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.
    112.05  Mental Retardation: Characterized by significantly 
subaverage general intellectual functioning with deficits in adaptive 
functioning.
    The required level of severity for this disorder is met when the 
requirements in A, B, C, D, E, or F are satisfied.
    A. 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;

OR

    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;

OR

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

OR

    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;

OR

    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;

OR

    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;

OR

    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

[[Page 453]]

    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

    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

[[Page 454]]

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;

OR

    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 
paragraphs B2 of 112.02.
    112.11  Attention Deficit Hyperactivity Disorder: Manifested by 
developmentally inappropriate degrees of inattention, impulsiveness, and 
hyperactivity.
    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 all three of the following:
    1. Marked inattention; and
    2. Marked impulsiveness; and
    3. Marked hyperactivity;

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;

OR

    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;

OR

    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;

OR

    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;

OR

    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

[[Page 455]]

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

    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. These disorders are described in 
part A, 14.00B.
    Some of the features of connective tissue disorders in children may 
differ from the features in adults. When the clinical features are the 
same as that seen in adults, the principles and concepts in part A, 
14.00B apply.
    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.
    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.
    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.
    In children the impairment may affect growth, development, 
attainment of age-appropriate skills, and performance of age-appropriate 
activities. The limitations may be the result of loss of function or 
failure in a single organ or body system, or a lesser degree of 
functional loss in two or more organs/body systems that, in combination 
with significant constitutional symptoms and signs of severe fatigue, 
fever, malaise, and weight loss, results in listing-level limitations. 
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.
    C. Allergies, growth impairments and Kawasaki disease.

[[Page 456]]

    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.

[[Page 457]]

    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

[[Page 458]]

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).

[[Page 459]]

             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.

or

    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.

or

    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.

or

    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.

or

    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.

or

    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

[[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.

or

    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.

or

    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.

or

    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.

or

    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.

or

    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 of 107.06 or 
7.06.

or

    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.

or

    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.

or

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

or

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

or

    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.

or


[[Page 461]]


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

or

    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.

or

    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]