00-2867. Technical Revisions to Medical Criteria for Determinations of Disability

AGENCY:

Social Security Administration (SSA).

ACTION:

Proposed rules.

SUMMARY:

We are proposing to make a number of technical revisions to the Listing of Impairments (the listings). We use the listings to adjudicate claims for disability under titles II and XVI of the Social Security Act (the Act) when we evaluate claims of individuals at steps 3 of our sequential evaluation processes for adults and children. The proposed changes reflect advances in medical knowledge, treatment, and terminology, clarify certain listing criteria, remove listings that we rarely use or that are redundant, and add new listings consistent with current medical practice.

These proposed revisions are technical changes that are intended to clarify or modify current language to improve understanding and usability. They are not intended to be a comprehensive update of the listings.

DATES:

To be sure that your comments are considered, we must receive them no later than April 11, 2000.

ADDRESSES:

Comments should be submitted in writing to the Commissioner of Social Security, P.O. Box 17703, Baltimore, MD 21235-7703, sent by telefax to [phone], sent by e-mail to “[e-mail]”, or delivered to the Office of Process and Innovation Management, Social Security Administration, L2109 West Low Rise Building, 6401 Security Boulevard, Baltimore, MD 21235-6401, between 8:00 a.m. and 4:30 p.m. on regular business days. Comments may be inspected during these hours by making arrangements with the contact person shown below.

FOR FURTHER INFORMATION CONTACT:

Carolyn Kiefer, Social Insurance Specialist, Office of Disability, Social Security Administration, 3-B-9 Operations Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, [phone] or TTY [phone].

SUPPLEMENTARY INFORMATION:

Background

Title II of the Act provides for the payment of disability insurance benefits to workers insured under the Act. Title II also provides, under certain circumstances, for the payment of child's insurance benefits for persons who become disabled before age 22 and widow's and widower's insurance benefits based on disability for widows, widowers, and surviving divorced spouses of insured individuals. In addition, title XVI of the Act provides for Supplemental Security Income (SSI) payments to persons who are aged, blind, or disabled and who have limited income and resources.

For adults under both the title II and title XVI programs and for persons claiming child's insurance benefits based on disability under the title II program, “disability” means that an impairment(s) results in an inability to engage in any substantial gainful activity. For an individual under age 18 claiming SSI benefits based on disability, “disability” means that an impairment(s) results in “marked and severe functional limitations.” Under both title II and title XVI, disability must be the result of any medically determinable physical or mental impairment(s) that can be expected to result in death or that has lasted or can be expected to last for a continuous period of at least 12 months.

The process for determining whether an individual (except for an individual under age 18 claiming SSI benefits based on disability) is disabled based on the statutory definition is set forth in our longstanding regulations at §§ 404.1520 and 416.920. These regulations provide for a sequential evaluation process for evaluating disability. There is a separate sequential evaluation process described in regulations at § 416.924 for individuals under age 18 claiming SSI benefits based on disability. At step 3 of both sequential evaluation processes we ask the same question: Whether an individual who is not engaging in substantial gainful activity and who has an impairment(s) that is severe, has an impairment(s) that meets or equals in severity the criteria of an impairment listed in appendix 1 of subpart P of part 404, the listings. The listings describe, for each of the major body systems, impairments that are considered severe enough to prevent a person from doing any gainful activity (or in the case of a child under age 18 claiming SSI benefits based on disability, to cause marked and severe functional limitations). Although the listings are contained only in part 404, they are referenced by subpart I of part 416.

The listings are divided into Part A and Part B. The criteria in Part A are applied in evaluating impairments of persons age 18 or over. The criteria in Part A may also be used to evaluate impairments in persons under age 18 if the disease processes have a similar effect on adults and children. In evaluating disability for a person under age 18, we first use the criteria in Part B and, if the criteria in Part B do not apply, we use the criteria in Part A (see §§ 404.1525 and 416.925).

These changes are not intended to be a comprehensive update and revision of the listings. We continue to review each of the body system listings to determine appropriate revisions and updates of a more substantive nature. If we determine that more substantive revisions are necessary, we will publish a notice in the Federal Register describing those proposed revisions and requesting public comments. Therefore, we are now requesting comments only on the specific technical changes we are proposing in this notice of proposed rulemaking.

The following is a detailed summary of the proposed revisions and our reasons for proposing these changes.

Explanation of Proposed Revisions

We propose to revise the language throughout all listings regarding references to “X-ray(s),” roentgenograms (which is another word for X-rays), and radiographic studies (which is another process similar to roentgenography), to include “other appropriate medically acceptable imaging” as satisfactory medical evidence. The proposed changes occur in the following sections and/or listings:

Sections 1.00A, 1.00B and 1.00C of the preface to the musculoskeletal body system and Listings 1.03, 1.04, 1.05, 1.08, 1.09, and 1.11;

Section 2.00B2 of the preface to the special senses and speech body system;

Section 4.00C3 of the preface to the cardiovascular system;

Section 5.00C of the preface to the digestive system and Listings 5.03, 5.04, and 5.05;

Listing 6.02C1 of the genito-urinary system;

Listing 7.16A of the hemic and lymphatic system;

Listing 9.03A of the endocrine system;

Listing 14.08M6 of the immune system;

Section 100.00B of the preface to growth impairments;

Listings 101.02A3 and 101.08 of the musculoskeletal system;

Listing 103.04B3 of the respiratory system;

Section 104.00E of the preface to the cardiovascular system;

Section 105.00B of the preface to the digestive system and Listings 105.05A and 105.05C;

Section 113.00B of the preface to the neoplastic diseases; and,

Listing 114.08N6 of the immune system.

We are proposing these changes to recognize that there have been significant advances in medical imaging, such as (but not limited to) computerized axial tomography (CAT scan) and magnetic resonance imaging (MRI), and to increase the types of evidence that can be used to meet the listings. Under §§ 404.1525 and 416.925 of our regulations, an individual's impairment “meets” the criteria of a given listing only by showing the same findings that are required in the listing. Because of this, an individual who has all of the findings required by a listing except X-ray evidence but who has the same or better information from a CAT scan, MRI, or other medically acceptable modern imaging technique than can be gotten from X-ray cannot meet the listing; instead, we must find that the individual's impairment medically equals the listing. The proposed changes would allow us to find that such individuals have impairments that meet these listings. We also made the proposed phrase nonspecific to allow for flexibility in the use of the use of the listings should new medically appropriate imaging techniques be developed in the future.

We are also proposing to add a brief explanation in the prefaces of the musculoskeletal adult and childhood listings (in paragraphs 1.00B and 101.00B, respectively) to explain what we mean by appropriate medically acceptable imaging techniques, and to explain that we will not purchase such expensive tests as CAT scans or MRIs in the course of obtaining documentation, but we will consider the results of these tests if they are available.

1.01 and 101.01 Category of Impairments, Musculoskeletal

We are making a correction to Listing 1.09 to move the word “of” to its proper placement following the parenthetical text that describes what we mean by “Amputation or anatomical deformity.” The “of” is currently incorrectly placed after the word “deformity,” and before the explanatory parenthetical language.

We are proposing to amend childhood Listing 101.08, Chronic osteomyelitis, to make it consistent with the language and criteria of adult Listing 1.08, which addresses osteomyelitis or septic arthritis. Since the adult listing is more complete and comprehensive, we are amending the childhood listing to be consistent with the adult listing.

2.00 and 102.00 Special Senses and Speech

We propose to revise the heading of 2.00A to read “Disorders of Vision” because the term currently used, “Ophthalmology,” is most commonly used to define the branch of medicine that deals with the anatomy, physiology, and pathology of the eye, whereas these listings, in fact, address visual disorders.

We propose to remove the word “central” in referring to vision and visual acuity throughout 2.00 and 102.00 because it is redundant. “Central vision” is medically synonymous with “visual acuity.” We propose to revise 2.00A1 to explain that diseases or injury of the eyes may result in loss of visual acuity or loss of the peripheral field. It is the loss of visual acuity that results in inability to distinguish detail and prevents reading and fine work, while the loss of the peripheral field restricts the ability of an individual to move about freely. We propose to clarify this section by stating that the extent of impairment of sight should be determined by visual acuity and peripheral field testing. Likewise, in 2.00A2, with the removal of the word “central,” we also propose to revise the opening sentence to clarify that loss of visual acuity may result in impaired distant and/or near vision (not “caused by” impaired vision).

Thus, we are proposing to remove the word “central” from the following: 2.00A1, 2.00A2, 2.00A5, 2.00A6, 2.02, Table No. 1 and its footnotes 2 and 3, 102.00A, and 102.02.

Also, we propose to further revise Table No. 1 by adding the word “acuity” to the first line of the chart, “Percent visual acuity efficiency,” and also to the title, “Percentage of Visual Acuity Efficiency Corresponding to Visual Acuity Notations * * *”.

Additionally, we propose clarifying the language of Listing 2.04 by replacing the phrase “central visual efficiency” with the phrase “visual acuity efficiency.”

We propose to revise 2.00B3 by removing the word “organic” from its title, removing the first sentence of the section, and amending the second sentence to clarify that the ability to produce speech by any means includes the use of mechanical or electronic devices that improve voice or articulation. Also in this section, we propose to correct the reference to “neurologic” disorders by appropriately calling them “neurological” disorders.

We propose to remove Listing 2.05, Complete homonymous hemianopsia (with or without macular sparing) because the language of 2.05 now directs that this disorder should be evaluated under Listing 2.04. Since we are not proposing to change Listing 2.04 in any substantive way, we will still use this listing to evaluate complete homonymous hemianopsia and there is no need to retain the separate listing.

We propose to revise Listing 2.09, Organic loss of speech, to remove the word “organic” because we believe that the cause of loss of speech (i.e., whether it is or is not “organic”) should be immaterial for purpose of applying this listing. We also propose to change the word “and” to “or” to clarify that the inability to produce speech that can be heard, understood, or sustained will meet the listing, instead of the requirement under the current language that all three of these factors be present. We believe that any one of these factors is sufficient to establish that an individual has a listing-level impairment.

3.00 and 103.00 Respiratory System

In the listing preface, we propose to revise some of the technical language dealing with the requirements for spirometry calibration and testing for diffusing capacity of the lungs for carbon monoxide (DLCO) to comply with the standards of current medical practice.

In 3.00E and 103.00B, Documentation of pulmonary function testing, we propose to revise the last sentence of the third paragraph of each section to explain that the testing device must have a daily recorded calibration of volume units performed sometime prior to the pulmonary function study. This revises the current requirement for separate calibration tracings to be performed at the time each pulmonary function test is performed. We believe a single daily calibration of the testing device is sufficient to provide accurate pulmonary measurements for purposes of our listings.

In 3.00F1, Diffusing capacity of the lungs for carbon monoxide (DLCO), fifth paragraph, fourth and fifth sentences, we are proposing the deletion of the reference to the algorithm used to calculate test results and the language regarding “independent calculation of results.” We believe this algorithm no longer needs to be provided in the documentation of DLCO since adjudicators are not expected to recompute the test results. Rather, we are asking that the file include documentation of the source of the predicted equation to permit adjudicators to verify that the test was performed adequately.

3.01 and 103.01 Category of Impairments, Respiratory System

We propose to add a new listing addressing lung transplants for both adults and children. Listing 3.11 for adults and Listing 103.05 for children, Lung transplant, is proposed to be consistent with other organ transplant listings and to provide that an individual undergoing a lung transplant will be considered under a disability for 12 months following the date of surgery with evaluation of any residual impairment thereafter.

4.00 and 104.00 Cardiovascular System

In 4.00A, Introduction, fourth paragraph, second sentence, and 104.00A, Introduction, sixth paragraph, second sentence, we propose to revise the language to change the word “make” to the word “consider” in the clause referring to making a medical equivalence determination in the case of an adult, and for children, a medical or functional equivalence determination. The current language could be misinterpreted to mean that, when 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 find that his or her impairment is medically equivalent to a listing, or for children, medically or functionally equivalent to a listing. Our intent has always been to indicate only that we will consider whether the impairment or combination of impairments is medically equivalent (or for children medically or functionally equivalent) to a listing. This is only a clarification of what we have always intended by the language in these sections.

5.00 and 105.00 Digestive System

As discussed above, we are proposing to amend Listings 5.05A and 105.05C to allow for documentation of esophageal varices by X-rays, endoscopy, or other appropriate medically acceptable imaging. This will allow for changes in medical technology over time and will eliminate the current unnecessary language differences in the parenthetical portion of these listings.

We propose to add a new listing to both the adult and childhood listings for the digestive system to address liver transplantation in keeping with our other organ transplantation listings. For adults, the new listing will be 5.09, Liver transplant; for children, it will be 105.09, Liver transplant.

Also, we are correcting a typographical error in 5.00C.

7.00 and 107.00 Hemic and Lymphatic System

We propose to add T-cell lymphoblastic lymphoma to the discussion of acute leukemia in sections 7.00E and 107.00C as well as in Listings 7.11 and 107.11. This disorder follows the same course and requires the same treatment as acute leukemia and is just as serious. By including this disorder in the preface and as a listed impairment in both the adult and childhood listings, we believe evaluation will be simplified by specifically directing adjudicators to the criteria for evaluating this disease.

We propose to amend the reference to bone marrow transplantation in Listing 7.17, Aplastic anemias or hematologic malignancies (excluding acute leukemia), to “bone marrow or stem cell transplantation” to add the new medical technique of stem cell transplantation which is comparable to bone marrow transplantation.

8.01 Category of Impairments, Skin

We are correcting a spelling error in Listing 8.06. The correct name of this impairment is Hidradenitis suppurative, acne conglobata.

9.01 Category of Impairments, Endocrine System

We propose to revise Listing 9.02, Thyroid Disorders, to remove paragraph A, which refers to “Progressive exophthalmos as measured by exophthalmometry,” because this complication now rarely occurs due to advances in treatment for thyroid disease.

11.00 and 111.00 Neurological

We are proposing changes in the language that we currently use for epilepsy and its treatment throughout these listings to make our listing language consistent with current medical terminology. For example, we propose changing the term “convulsive disorders” in 11.00A to “epilepsy,” and changing the references to “anticonvulsive” treatment and drugs to “antiepileptic” treatment and drugs to reflect current medical terminology. In keeping with these changes in terminology, we are also proposing changing the descriptions of the categories of epilepsy under Listings 11.02 and 11.03 in Part A, and Listings 111.02 and 111.03 in Part B. In place of the term major motor seizures (11.02 and 111.02) we are proposing “convulsive epilepsy,” and for the term minor motor seizures (11.03 and 111.03), we are proposing “nonconvulsive epilepsy.” These terms are in keeping with current medical terminology.

We also propose to remove the requirement for electroencephalogram (EEG) evidence to support the existence of epilepsy throughout the neurological listings with the exception of cases involving nonconvulsive epilepsy in children. This is the only category of epilepsy in which an EEG is the definitive diagnostic tool; in all other situations of epilepsy, it is rare for an EEG to confirm the presence of a seizure disorder.

We propose to amend the language of Listing 111.02B3 by changing it from “significant emotional disorder” to “significant mental disorder.” This clarifies the nature of the impairment identified, i.e., a defined mental impairment, and is consistent with other listing terminology.

We propose to remove Listing 11.15, Tabes dorsalis, because the availability of effective screening tests and treatment have markedly reduced the incidence of this disorder. With the capability to do early identification and treatment in cases of syphilis, the disease that leads to Tabes dorsalis, we believe this listing is no longer needed.

With the proposal to remove Listing 11.15, we are also proposing to remove the reference to 11.15B currently in Listing 11.17A, which deals with disorganization of motor function in degenerative diseases such as Huntington's chorea and Friedreich's ataxia. The disorganization of motor function described in Listing 11.04B includes disturbances of gait as described in 11.15B, so we believe that the reference to 11.04B is sufficient to address the manifestations of the degenerative diseases covered by Listing 11.17.

12.01 and 112.01 Category of Impairments, Mental

We are proposing to highlight a portion of the language in the capsule definition of Listing 12.05 by italicizing it. Listing 12.05 deals with mental retardation and autism. Mental retardation is defined as a significantly subaverage general intellectual functioning with deficits in adaptive behavior initially manifested during the developmental period (before age 22). To draw the user's attention to the portion dealing with the time period for the manifestations of these deficits, we propose to italicize the text initially manifested during the developmental period (before age 22).

We are proposing to correct an error in Listing 112.05F1 and 112.05F2. The word “limitations” should be “limitation.” This is consistent with the wording of the adult Listing 12.05C, “imposing additional and significant work-related limitation of function.”

13.01 Category of Impairments, Neoplastic Diseases—Malignant

We propose to amend Listing 13.08, Thyroid gland, adding another criterion, “Anaplastic carcinoma of the thyroid.” This would be designated as 13.08B, and the current listing language would become 13.08A. Anaplastic carcinoma of the thyroid is a distinct type of carcinoma that can be specified as part of this listing because it is of the same level of severity as the current listing and has a poor prognosis. We believe that identifying it separately will assist adjudicators in evaluating thyroid neoplasms.

Clarity of These Proposed Rules

Executive Order 12866 and the President's memorandum of June 1, 1998, (63 F.R. 31885), require each agency to write all rules in plain language. In addition to your substantive comments on these proposed rules, we invite your comments on how to make these proposed rules easier to understand.

For example:

• Have we organized the material to suit your needs?
• Are the requirements in these rules clearly stated?
• Do the rules contain technical language or jargon that isn't clear?
• Would a different format (grouping and order of sections, use of headings, paragraphing) make these rules easier to understand?
• Would more (but shorter) sections be better?
• Could we improve clarity by adding tables, lists, or diagrams?
• What else could we do to make these rules easier to understand?

Electronic Versions

The electronic file of this document is available on the internet at http://www.access.gpo.gov/​su_​docs/​aces/​aces140.html. It is also available on the internet site for SSA (i.e., “SSA Online”) at http://www.ssa.gov/​.

Regulatory Procedures

Executive Order 12866

We have consulted with the Office of Management and Budget (OMB) and determined that these proposed regulations do not meet the criteria for a significant regulatory action under Executive Order 12866. Thus, they were not subject to OMB review.

Regulatory Flexibility Act

We certify that these proposed regulations will not have a significant economic impact on a substantial number of small entities because they affect only individuals. Thus, a regulatory flexibility analysis as provided in the Regulatory Flexibility Act, as amended, is not required.

Paperwork Reduction Act

These proposed regulations will impose no additional reporting or recordkeeping requirements requiring OMB clearance.

(Catalog of Federal Domestic Assistance Program Nos. 96.001, Social Security-Disability Insurance; 96.006, Supplemental Security Income)

List of Subjects

20 CFR Part 404

• Administrative practice and procedure
• Blind
• Disability benefits
• Old-Age
• Survivors and Disability Insurance
• Reporting and recordkeeping requirements
• Social Security

20 CFR Part 416

• Administrative practice and procedure
• Aged
• Blind
• Disability benefits
• Public assistance programs
• Reporting and recordkeeping requirements
• Supplemental Security Income

Dated: January 28, 2000.

Kenneth S. Apfel,

Commissioner of Social Security.

For the reasons set forth in the preamble, we are proposing to amend part 404, subpart P, and part 416, subpart I of chapter III of title 20 of the Code of Federal Regulations as follows:

PART 404—FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- )

Subpart P [Amended]

1. The authority citation for subpart P of part 404 continues to read as follows:

Authority: Secs. 202, 205(a), (b), and (d)-(h), 216(i), 221(a) and (i), 222(c), 223, 225, and 702(a)(5) of the Social Security Act (42 U.S.C. 402, 405(a), (b), and (d)-(h), 416(i), 421(a) and (i), 422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193, 110 Stat. 2105, 2189.

Appendix 1 to Subpart P of Part 404—[Amended]

2. Appendix 1 to subpart P of part 404 is amended as follows:

a. Section 1.00 in part A of appendix 1 is amended:

(1) By revising the last sentence of paragraph A;

(2) By revising the first sentence in the second paragraph of paragraph B;

(3) By adding a new eighth paragraph to paragraph B; and,

(4) By revising paragraph C;

b. Section 1.03 in part A of appendix 1, paragraph A is revised.

c. Section 1.04 in part A of appendix 1 is amended by revising the introductory text.

d. Section 1.05 in part A of appendix 1 is amended by revising the introductory text in paragraphs A and B.

e. Section 1.08 in part A of appendix 1 is amended by revising the heading.

f. Section 1.09 in part A of appendix 1 is amended by revising the heading.

g. Section 1.11 in part A of appendix 1 is revised.

h. Section 2.00 in part A of appendix 1 is amended:

(1) By revising the heading of paragraph A;

(2) By revising paragraph A1, the first two sentences of paragraph A2, and paragraph A5;

(3) By amending paragraph A6 to remove the word “central” in the first, fourth, fifth, and sixth sentences;

(4) By revising the last sentence in the third paragraph of paragraph B2;

(5) By revising paragraph B3;

(6) By amending Table No. 1 by revising the heading to read, “Percentage of visual acuity efficiency corresponding to visual acuity notations for distance in the phakic and aphakic eye (better eye)” by revising the heading of the right column on the first line of the table to read, “Percent visual acuity efficiency”; and by amending footnotes 2 and 3 to Table No. 1 by removing the word “central.”

i. Section 2.02 in part A of appendix 1 is amended by removing the word “central” in the heading.

j. Section 2.04 in part A of appendix 1 is revised.

k. Section 2.05 in part A of appendix 1 is removed and reserved.

l. Section 2.09 in part A of appendix 1 is revised.

m. Section 3.00 in part A of appendix 1 is amended by revising the last sentence in the third paragraph of paragraph E, and by amending paragraph F1 by revising the fourth and fifth sentences of the fifth paragraph.

n. Section 3.11 in part A of appendix 1 is added.

o. Section 4.00, paragraph A, in part A of appendix 1 is amended in the second sentence of the fourth paragraph by revising “make” to read “consider”, and in paragraph C3 by amending the third sentence of the first paragraph.

p. Section 5.00, paragraph C, in part A of appendix 1 is amended in the fourth sentence by revising “roentgenograms” to read “X-rays or other appropriate medically acceptable imaging,” and by revising “impairmentich” to read “impairment which.”

q. Section 5.03 in part A of appendix 1 is revised.

r. Section 5.04 in part A of appendix 1 is amended by revising the heading and by revising paragraph C.

s. Section 5.05 in part A of appendix 1 is amended by revising the first sentence in paragraph A.

t. Section 5.09 in part A of appendix 1 is added.

u. Section 6.02 in part A of appendix 1 is amended by revising paragraph C1.

v. Section 7.00 in part A of appendix 1 is amended by revising the heading and the first sentence of the first paragraph of paragraph E.

w. Section 7.11 in part A of appendix 1 is amended by revising the heading.

x. Section 7.16 in part A of appendix 1 is amended by revising paragraph A.

y. Section 7.17 in part A of appendix 1 is amended by revising the first sentence.

z. Section 8.06 in part A of appendix 1, the heading is amended by revising “Hydradenitis” to read “Hidradenitis.”

aa. In section 9.02 in part A of appendix 1, the word “With:” following the heading and paragraph A are removed and the paragraph designation “B” is removed from paragraph B.

bb. Section 9.03, paragraph A, in part A of appendix 1 is revised.

cc. Section 11.00, paragraph A, in part A of appendix 1 is amended by revising the heading, by revising the first sentence in the first paragraph, by removing the second paragraph, by redesignation the third paragraph as the second paragraph and by amending the first, second and third sentences in the redesignating second paragraph to revise the word “anticonvulsive” to read “antiepileptic.”

dd. Section 11.02 in part A of appendix 1 is amended by revising the heading.

ee. Section 11.03 in part A of appendix 1 is amended by revising the heading.

ff. Section 11.15 in part A of appendix 1 is removed and reserved.

gg. Section 11.17, paragraph A, in part A of appendix 1 is amended by removing the words “or 11.15B”.

hh. Section 12.05 in part A of appendix 1 is amended by revising the first sentence of the introductory text.

ii. Section 13.08 in part A of appendix 1 is revised.

jj. Section 14.08 in part A of appendix 1 is amended by revising paragraph M6.

kk. Section 100.00, paragraph B, in part B of appendix 1 is revised.

ll. Section 101.00, paragraph B, in part B of appendix 1 is amended by adding a second paragraph.

mm. Section 101.02, paragraph A3, in part B of appendix 1 is revised.

nn. Section 101.08 in part B of appendix 1 is revised.

oo. Section 102.00 in part B of appendix 1, is amended by removing the word “central” from the first and second sentences of paragraph A.

pp. Section 102.02 in part B of appendix 1 is amended by removing the word “central” from the heading.

qq. Section 103.00, paragraph B, in part B of appendix 1 is amended by revising last sentence of the third paragraph.

rr. Section 103.04, paragraph B3, in part B of appendix 1 is revised.

ss. Section 103.05 in part B of appendix 1 is added after Table III.

tt. Section 104.00, paragraph A, in part B of appendix 1 is amended in the last sentence of the sixth paragraph by revising “make a determination” to read “consider,” and paragraph E is amended by revising the first sentence of the third paragraph.

uu. Section 105.00 in part B of appendix 1, is amended to revise the first sentence in paragraph B.

vv. Section 105.05, paragraphs A and C, in part B of appendix 1 are revised.

ww. Section 105.09 in part B of appendix 1 is added.

xx. Section 107.00, paragraph C, in part B of appendix 1 is amended by revising the heading and by revising the first sentence of the first paragraph.

yy. Section 107.11 in part B of appendix 1 is amended by revising the heading.

zz. Section 111.00 in part B of appendix 1, paragraph A is revised and paragraph B is amended by revising the heading, and by removing the second sentence.

aaa. Section 111.02 in part B of appendix 1 is amended by revising the headings of paragraphs A and B; by revising the first sentence of the introductory text of paragraphs A and B; and by revising paragraph B3.

bbb. Section 111.03 in part B of appendix 1 is amended by revising the heading.

ccc. Section 112.05, paragraphs F1 and F2, in part B of appendix 1 are amended by revising “limitations” to read “limitation.”

ddd. Section 113.00 in part B of appendix 1, is amended by revising the third sentence in paragraph B.

eee. Section 114.08, paragraph N6, in part B of appendix 1, paragraph N6 is revised.

The added and revised text is as follows:

Appendix 1 to Subpart P of Part 404-Listing of Impairments

* * * * *

1.00 Musculoskeletal System

A. * * * 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 abnormalities as shown by X-ray or other appropriate medically acceptable imaging.

B. * * *

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 or other appropriate medically acceptable imaging. * * *

* * * * *

Medically acceptable imaging includes, but is not limited to, X-ray imaging, computerized axial tomography (CAT scan), magnetic resonance imaging (MRI), with or without contrast material, and radionuclear bone scans. While any appropriate medically acceptable imaging is useful in establishing the diagnosis of musculoskeletal impairments, some tests, such as CAT scans and MRIs are quite expensive and some, such as myelograms, are invasive and may involve significant risk. If the results of these tests are available from the claimant or other sources at no or minimal cost to the agency, they will be considered in the evaluation of the claim. However, expensive tests and tests that may involve significant risk to the claimant, such as myelograms, will not be ordered.

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 findings as shown by x-rays or other appropriate medically acceptable imaging techniques for any 6-month period after the last definitive surgical procedure, evaluation should be made on the basis of demonstrable residuals.

* * * * *

1.03 Arthritis of a major weight-bearing joint (due to any cause):

* * * * *

A. Gross anatomical deformity of hip or knee (e.g., subluxation, contracture, bony or fibrous ankylosis, instability) supported by x-ray or other appropriate medically acceptable imaging evidence showing either significant joint space narrowing or significant bony destruction, and markedly limiting ability to walk or stand; or,

* * * * *

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 or other appropriate medically acceptable imaging evidence of either significant joint space narrowing or significant bony destruction. With:

* * * * *

1.05 Disorders of the spine:

A. Arthritis manifested by ankylosis or fixation of the cervical or dorsolumbar spine at 30° or more of flexion measured from the neutral position, with X-ray or other appropriate medically acceptable imaging evidence of:

* * * * *

B. Osteoporosis, generalized (established by X-ray or other appropriate medically acceptable imaging) manifested by pain and limitation of back motion and paravertebral muscle spasm with X-ray or other appropriate medically acceptable imaging evidence of either:

* * * * *

1.08 Osteomyelitis or septic arthritis (established by X-ray or other appropriate medically acceptable imaging):

* * * * *

1.09 Amputation or anatomical deformity (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 or other appropriate medically acceptable imaging evidence of bony ankylosis at an unfavorable angle, joint subluxation or instability) of:

* * * * *

1.11 Fracture of the femur, tibia, tarsal bone or pelvis with solid union not evident on X-ray or other appropriate medically acceptable imaging, 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.

* * * * *

2.00 Special Senses and Speech

A. Disorders of Vision

1. Causes of impairment. Diseases or injury of the eyes may produce loss of visual acuity or loss of the peripheral field. Loss of visual acuity results in inability to distinguish detail and prevents reading and fine work. Loss of the peripheral field restricts the ability of an individual to move about freely. The extent of impairment of sight should be determined by visual acuity and peripheral field testing.

2. Visual acuity. Loss of visual acuity may result in 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 visual acuity for distance of the better eye with best correction based on the Snellen test chart measurement may be used. * * *

* * * * *

5. Visual efficiency. Loss of visual efficiency may be caused by disease or injury resulting in reduction of visual acuity or visual field. The visual efficiency of one eye is the product of the percentage of visual acuity efficiency and the percentage of visual field efficiency. (See tables no. 1 and 2, following 2.09.)

* * * * *

B. * * *

2. * * *

* * * * *

* * * When polytomograms, 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 or other appropriate medically acceptable imaging.

3. Loss of speech. In evaluating the loss of speech, the ability to produce speech by any means includes the use of mechanical or electronic devices that improve voice or articulation. Impairment of speech due to neurological disorders should be evaluated under 11.00—11.19.

* * * * *

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 visual acuity efficiency and the percent of remaining visual field efficiency.)

2.05 [Removed and reserved]

* * * * *

2.09 Loss of speech due to any cause with inability to produce by any means speech which can be heard, understood, or sustained.

* * * * *

3.00 Respiratory System

* * * * *

E. Documentation of pulmonary function testing.

* * * * *

* * * If the spirogram was generated by any means other than direct pen linkage to a mechanical displacement-type spirometer, the testing device must have had a recorded calibration performed previously on the day of the spirometric measurement.

* * * * *

F. Documentation of chronic impairment of gas exchange.

1. * * *

* * * * *

* * * The percentage concentrations of inspired O₂ and inspired and expired CO and He for each of the maneuvers should be provided. Sufficient data must be provided, including documentation of the source of the predicted equation, to permit verification that the test was performed adequately, and that, if necessary, corrections for anemia and/or carboxyhemoglobin were made appropriately.

* * * * *

3.11 Lung transplant. Consider under a disability for 12 months following surgery; thereafter, evaluate the residual impairment.

4.00 Cardiovascular System

* * * * *

C. * * *

3. * * * In selected cases, these tests may be purchased after a medical history and physical examination, report of chest x-rays or other appropriate medically acceptable imaging, ECGs, and other appropriate tests have been evaluated, preferably by a program physician with experience in the care of patients with cardiovascular disease. * * *

5.03 Stricture, stenosis, or obstruction of the esophagus (demonstrated by X-ray, endoscopy, or other appropriate medically acceptable imaging) with weight loss as described under listing 5.08.

5.04 Peptic ulcer disease (demonstrated by X-ray, endoscopy, or other appropriate medically acceptable imaging). With:

* * * * *

C. Recurrent obstruction demonstrated by X-ray, endoscopy, or other appropriate medically acceptable imaging; or,

* * * * *

5.05 Chronic liver disease (e.g., portal, postnecrotic, or biliary cirrhosis; chronic active hepatitis; Wilson's disease). * * *

A. Esophageal varices (demonstrated by X-ray, endoscopy, or other appropriate medically acceptable imaging) with a documented history of massive hemorrhage attributable to these varices. * * *

* * * * *

5.09 Liver transplant. Consider under a disability for 12 months following surgery; thereafter, evaluate the residual impairment.

* * * * *

6.02

* * * * *

C. * * *

1. Renal osteodystrophy manifested by severe bone pain and abnormalities shown by appropriate radiographic or other medically acceptable imaging (e.g., osteitis fibrosa, marked osteoporosis, pathologic fractures); or

* * * * *

7.00 Hemic and Lymphatic System

* * * * *

E. Acute leukemia or T-cell lymphoblastic lymphoma. Initial diagnosis of acute leukemia or T-cell lymphoblastic lymphoma must be based upon definitive bone marrow pathologic evidence. * * *

* * * * *

7.11 Acute leukemia or T-cell lymphoblastic lymphoma.

* * * * *

7.16 Myeloma (confirmed by appropriate serum or urine protein electrophoresis and bone marrow findings). With:

A. Radiologic or other appropriate medically acceptable imaging evidence of bony involvement with intractable bone pain; or

* * * * *

7.17 Aplastic anemias or hematologic malignancies (excluding acute leukemia): With bone marrow or stem cell transplantation. * * *

* * * * *

9.03 Hyperparathyroidism. With:

A. Generalized decalcification of bone on X-ray or other appropriate medically acceptable imaging study and elevation of plasma calcium to 11 mg. per deciliter (100 ml.) or greater; or

* * * * *

11.00 Neurological

A. Epilepsy. In epilepsy, regardless of etiology degree of impairment will be determined according to type, frequency, duration, and sequelae of seizures. * * *

* * * * *

11.02 Epilepsy-convulsive epilepsy, (grand mal or psychomotor), documented 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.

* * * * *

11.03 Epilepsy-nonconvulsive epilepsy (petit mal, psychomotor, or focal), documented 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.

* * * * *

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). * * *

* * * * *

13.08 Thyroid gland:

A. Carcinoma with metastases beyond the regional lymph nodes, not controlled by prescribed therapy; or

B. Anaplastic carcinoma of the thyroid.

* * * * *

14.08 Human immunodeficiency virus (HIV) infection.

* * * * *

M. * * *

6. Sinusitis documented by radiography or other appropriate medically acceptable imaging.

* * * * *

100.00 Growth Impairment

* * * * *

B. Bone age determinations should include a full descriptive report of roentgenograms or other medically acceptable imaging specifically obtained to determine bone age and must cite the standardization method used. Where roentgenograms or other appropriate medically acceptable imaging must be obtained currently as a basis for adjudication under 100.03, views or scans of the left hand and wrist should be ordered. In addition, roentgenograms or other appropriate medically acceptable imaging of the knee and ankle should be obtained when cessation of growth is being evaluated in an older child at, or past, puberty.

* * * * *

101.00 Musculoskeletal System

* * * * *

B. * * *

Medically acceptable imaging includes, but is not limited to, X-ray imaging, computerized axial tomography (CAT scan), magnetic resonance imaging (MRI), with or without contrast material, and radionuclear bone scans. While any appropriate medically acceptable imaging is useful in establishing the diagnosis of musculoskeletal impairments, many tests, such as CAT scans and MRIs are quite expensive and some, such as myelograms, are invasive and may involve significant risk. If the results of these tests are available from the claimant or other sources at no or minimal cost to the agency, they will be considered in the evaluation of the claim. However, expensive tests and tests that may involve significant risk to the claimant, such as myelograms, will not be ordered.

* * * * *

101.02 Juvenile rheumatoid arthritis.

* * * * *

A. * * *

3. Radiographic or other appropriate medically acceptable imaging evidence showing joint narrowing, erosion, or subluxation; or

* * * * *

101.08 Osteomyelitis or septic arthritis (established by X-ray or other appropriate medically acceptable imaging):

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

B. Multiple localizations and systemic manifestations as in A. above.

* * * * *

103.00 Respiratory System

* * * * *

B. * * *

* * * * *

* * * If the spirogram was generated by any means other than direct pen linkage to a mechanical displacement-type spirometer, the testing device must have had a recorded calibration performed previously on the day of the spirometric measurement.

* * * * *

103.04 Cystic fibrosis.

* * * * *

B. * * *

3. Radiographic or other appropriate medically acceptable imaging evidence of extensive disease, such as thickening of the proximal bronchial airways or persistence of bilateral peribronchial infiltrates; or

* * * * *

103.05 Lung transplant. Consider under a disability for 12 months following surgery; thereafter, evaluate the residual impairment.

* * * * *

104.00 Cardiovascular System

* * * * *

E. * * *

Findings of cardiomegaly shown by chest x-ray or other appropriate medically acceptable imaging evidence must be accompanied by other evidence of chronic heart failure or ventricular dysfunction. * * *

* * * * *

105.00 Digestive System

* * * * *

B. Documentation of gastrointestinal impairments should include pertinent operative findings, radiographic or other appropriate medically acceptable imaging studies, endoscopy, and biopsy reports. * * *

* * * * *

105.05 Chronic liver disease. * * *

A. Inoperable billiary atresia demonstrated by X-ray or other appropriate medically acceptable imaging or surgery; or

* * * * *

C. Esophageal varices (demonstrated by X-rays, endoscopy, or other appropriate medically acceptable imaging); or

* * * * *

105.09 Liver transplant. Consider under a disability for 12 months following surgery; thereafter, evaluate the residual impairment.

* * * * *

107.00 Hemic and Lymphatic System

* * * * *

C. Acute leukemia or T-cell lymphoblastic lymphoma. Initial diagnosis of acute leukemia or T-cell lymphoblastic lymphoma must be based upon definitive bone marrow pathologic evidence. * * *

* * * * *

107.11 Acute leukemia or T-cell lymphoblastic lymphoma. * * *

* * * * *

111.00 Neurological

A. Convulsive epilepsy must be substantiated by at least one detailed description of a typical seizure. Report of recent documentation should include a neurological examination with frequency of episodes and any associated phenomena substantiated.

Young children may have convulsions in association with febrile illnesses. Proper use of 111.02 and 111.03 requires that epilepsy 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 epilepsy when treatment is started, particularly when changes in the treatment regimen are necessary. Therefore, an epileptic disorder should not be considered to meet the requirements of 111.02 or 111.03 unless it is shown that convulsive episodes have persisted more than three months after prescribed therapy began.

B. Nonconvulsive epilepsy. * * *

* * * * *

111.02 Major motor seizure disorder.

A. Convulsive epilepsy. In a child with an established diagnosis of epilepsy, the occurrence of more than one major motor seizure per month despite at least three months of prescribed treatment. * * *

* * * * *

B. Convulsive epilepsy syndrome. In a child with an established diagnosis of epilepsy, the occurrence of at least one major motor seizure in the year prior to application despite at least three months of prescribed treatment. * * *

* * * * *

3. Significant mental disorder; or

* * * * *

111.03 Nonconvulsive epilepsy. * * *

* * * * *

113.00 Neoplastic Diseases, Malignant

* * * * *

B. Documentation. * * * 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 or reports from other appropriate medically acceptable imaging.* * *

* * * * *

114.08 Human immunodeficiency virus (HIV) infection.

* * * * *

N. * * *

6. Sinusitis documented by radiography or other appropriate medically acceptable imaging.

* * * * *

PART 416—SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND DISABLED

Subpart I—[Amended]

3. The authority citation for subpart I of part 416 continues to read as follows:

Authority: Secs. 702(a)(5), 1611, 1614, 1619, 1631(a), (c) and (d)(1), and 1633 of the Social Security Act (42 U.S.C. 902 (a)(5), 1382, 1382c, 1382h, 1383(a), (c), and (d)(1), and 1383b); secs. 4(c) and 5, 6(c)-(e), 14(a) and 15, Pub. L. 98-460, 98 Stat. 1794, 1801, 1802, and 1808 (42 U.S.C. 421 note, 423 note, 1382h note).

§ 416.926

[Amended]

4. Section 416.926a is amended by removing paragraphs (d) (8) and (9), and redesignating paragraph (d) (10), (11), and (12) as paragraphs (d) (8), (9), and (10).